Inspection on 08/08/05 for Queen Mary`s and Mulberry House Nursing Home

This inspection was carried out on 8th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Queen Mary`s and Mulberry House... 12/09/06

Queen Mary`s and Mulberry House... 13/12/05

Queen Mary`s and Mulberry House... 24/02/05

Queen Mary`s and Mulberry House... 13/11/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Queen Marys 7 Hollington Park Road St Leonards-on-sea East Sussex TN38 0SE Lead Inspector Niki Palmer Unannounced 8 August 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Queen Marys Address 7 Hollington Park Road St Leonards-on-sea East Sussex TN38 0SE 01424 423692 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Galleon Care Homes Limited Ms Julie Lowes Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (OP), 53 of places Physical disability (PD) Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Old age, aged 65 years or over on admission, not falling into any other category (OP) 2. People with a physical disability aged 50 years or over on admission (PD) 3. Maximum number to be accommodated at any one time is 53 Date of last inspection 24 February 2005 Brief Description of the Service: Queen Mary’s is a large adapted house situated in a quiet residential area of St Leonard’s on Sea. A new purpose built wing was added to the home and completed in November 2004, increasing its registration numbers to 53. Bedroom accommodation is provided over three floors with shaft lifts fitted to ensure level access to all areas of the home for residents. There are large communal gardens and patio areas to three sides of the home, which have recently been landscaped. Local shops are approximately half a mile distance and St Leonard’s town Centre with its access to bus and rail routes approximately one mile away. Queen Mary’s is registered to accommodate up to 53 older people who may require nursing care, and adults aged over 50 years who may have a physical disability. Queen Mary’s is owned by Galleon Care Homes, who provide two other care homes within East Sussex. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Queen Mary’s Care Home will be referred to as ‘residents’. This unannounced inspection took place on a Monday between 10.00am and 4.00pm. The inspection began with discussions with the deputy manager of the care home in respect of progress made since the last inspection, followed by the examination of eight care records. In order to gather evidence on how the home is performing, individual discussions took place with six residents, whilst others commented on their care during lunchtime, the inspector having been invited to join them for a meal. In addition, four care staff were spoken with during the visit, three registered nurses and two visiting relatives. An inspection of the premises and its facilities took place. 47 residents were accommodated at the time of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4, 5 and 6. Detailed written information is provided to all prospective residents and their relatives prior to admission in order to help them in their decision of where to live. This home has good procedures in place to ensure that no person is admitted to the home whose needs cannot be met. EVIDENCE: Many of the residents and relatives spoken with said that Queen Mary’s had been recommended to them by friends / family or health and social care professionals. The home updated its Statement of Purpose and Service Users’ Guide in April 2005, both were found to be very detailed. The Service Users’ Guide contains details of the home’s aims and objectives and philosophy of care, staffing levels, the accommodation provided, contact details of the Commission for Social Care Inspection and useful contact addresses. Two of the relatives and three of the residents spoken with confirmed that they had been provided with these documents prior to admission. Although the Service Users’ Guide included a copy of an inspection report, it was not the most recent. A recommendation has been made in respect of this. A thorough assessment of individual needs is usually carried out by the Registered Manager or Deputy Manager of the home prior to admission. This was confirmed by residents and their relatives. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 8 Concerns were raised during the previous inspection regarding the home’s procedures for admitting residents on an emergency basis. New policies and procedures were implemented in April 2005. The home will now only admit residents on an emergency basis once they have received verbal information from the person’s General Practitioner, and / or Social Worker, the individual and their family. A thorough full assessment is carried out at the homes earliest convenience, usually within five days of admission. Four pre-admission assessments were seen during the inspection, one of which had been carried out on the day an the emergency admission. All were found to contain clear and thorough details of the person’s level of need, all areas of daily living, likes and dislikes and any mental health needs. One of the assessments seen clearly stated the reasons as to why the person was not considered suitable. Intermediate care is not provided. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9. This home has good systems in place to plan for the care needs of residents and good procedures for the administration of prescribed medicines. EVIDENCE: Four individual plans of care were seen during the inspection. All were found to contain identified long-term needs and the action that is to be taken by nursing and care staff to ensure the needs are met. Since the last inspection the home has worked hard to ensure that individuals’ mental health and social care needs are incorporated within the plans of care. A number of risk assessments are in place for the prevention of falls, nutrition and maintaining pressure area care, however there was no evidence that any of the care plans seen had been shared with residents or their relatives. The home has detailed procedures in place for staff to follow regarding maintaining the personal care needs of residents including: oral care, manual handling, pressure area care and the care of a resident with MRSA. All of the care plans seen provided clear guidance to staff in relation to individual needs and preferences. Regular input and advice is received from a tissue viability nurse and a dietician where necessary. Residents confirmed that they are given a choice of a General Practitioner where possible. The homes medicine storage and administration system was viewed. The home uses a monitored dosage system provided by the local pharmacy. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 10 All medicines were found to be stored appropriately and clearly labelled. A sample of controlled drugs were examined and no errors found. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15. The arrangements in place for the provision of daily social activities are managed well by the home. All residents receive a varied, wholesome and nutritious diet. EVIDENCE: All residents’ preferences and choice of leisure activities are assessed by the activities coordinator shortly after admission to the home. These assessments were found to be very thorough and detailed. The activities coordinator is employed by Galleon Care Homes and shares her time between each of the three homes. She is usually based at Queen Mary’s on a Wednesday and Thursday afternoon, although recently she has been helping out at one of the other homes on a full-time basis. Residents and their relatives commented that this has had an impact on the activities provided at Queen Mary’s. There are large communal gardens surrounding Queen Mary’s, which some residents choose to use. One of the residents likes to grow her own flowers and keep the patio area tidy, whilst others choose to remain in their rooms, watch television or read. On the day of inspection many visitors were seen to visit the home and take their friends / relatives out for a short walk, or just sit in the garden or lounge area talking. All residents and relatives spoken with confirmed that visitors are made welcome at anytime during the day. Residents are encouraged to dine in the dining area, although some choose to remain in their bedrooms. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 12 The lunchtime meal was found to be relaxed and calm. Staff were seen to offer discreet support to those who needed it. All residents are offered a choice of two hot meals and desserts for lunch and a lighter option in the evening. All menus are planned in advance with special dietary needs catered for. All of the residents spoken with confirmed that all meals are hot, tasty and nutritious. A variety of hot and cold soft drinks such as tea, coffee and squash are available throughout the day and evening. Two of the residents spoken with confirmed that alcoholic drinks are available on request. It was pleasing to note that on the day of inspection it was one of the residents’ birthday. A homemade cake had been prepared by the chef, whilst the nursing and care staff sang happy birthday. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home needs to ensure that all residents and their relatives are aware of the home’s complaints procedure. Adequate policies and procedures are in place for the protection of vulnerable adults. EVIDENCE: No complaints have been received by the home or the CSCI since the last inspection. The home has a detailed procedure in place for handling complaints, however it was concerning to note that none of the residents or relatives spoken with were aware of this as it is not currently contained within the Service Users’ Guide. Although it is displayed within the main entrance area of the home, it is not easily visible or in a format that is easy to read. It was pleasing to note however, that those residents spoken with would in the first instance address their concerns with the Registered Manager of the home. The home has a detailed Adult Protection procedure and Whistle blowing policy in place to safeguard residents from harm. It has been drawn up in accordance with local multi-agency and Department of Health guidelines. It details definitions of what constitutes abuse, different types of abuse and how care staff should report any suspected incidents. Care and nursing staff spoken with confirmed that the majority had attended recent training in respect of the Protection of Vulnerable Adults whilst others are due to attend a one day course in September 2005. It was pleasing to note that since the last inspection, the home has amended its policy regarding restraint in line with good practice guidelines. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 23, 24 and 26. Queen Mary’s provides residents with a safe, comfortable and well-maintained place to live. EVIDENCE: Queen Mary’s care home comprises of 51 single bedrooms – 45 of which have en-suite facilities, and one double room also with en-suite. The home is wellmaintained throughout both internally and externally by a number of domestic staff and a full-time maintenance person. Communal areas are provided on the ground floor and are furnished and decorated to a high standard. Many of the residents and their relatives commented on the fact that the home is always clean throughout and presents as homely and attractive. A number of bedrooms were viewed during the inspection. Many of the rooms had been furnished with individuals’ personal belongings. Photographs and pictures were also on display in most of the rooms. One of the residents spoken with said that she viewed Queen Mary’s as her home now and that she was ‘lucky to have found it’. All residents’ bedrooms are carpeted and provide a bedside table, bed (specialist if necessary), wardrobe and a chest of drawers. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 15 All curtains and furnishings were clean and well-maintained. A laundry person is employed to manage all washing and ironing. The laundry area consists of two industrial washing machines and two tumble dryers. All clothing is ironed. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30. Queen Mary’s ensures adequate staffing levels and a high standard of staff training to meet the care and nursing needs of residents. EVIDENCE: Queen Mary’s employs a total of 48 staff, comprising of nine Registered General Nurses, 12 care assistants – four of which are trained to at least NVQ level 2 in care, housekeeping staff, an administrator and kitchen staff. There are two Registered Nurses on duty at all times and at least 10 care assistants during the day. Staffing teams are allocated on each of the three floors. Residents, relatives and staff stated that there are always enough staff on duty to meet the needs of the residents accommodated. Two new care assistants were spoken with on the day of the inspection, both of which confirmed that they had received a thorough induction to the home within their first week. All staff are required to complete a training programme within the first four weeks of employment. Working practices covered include: the home’s call system, manual handling, abuse, COSHH and the safe disposal of clinical waste amongst others. Nurses study days take place on a regular basis throughout the year both internally and externally. All courses are advertised in the home’s staff room. Forthcoming events include: urinary catheterisation, dealing with dementia and challenging behaviours, palliative symptom control and Adult Protection. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 37 and 38. Queen Mary’s has adequate management and administration systems in place, but work is needed to ensure that the views of residents and relatives are sought in respect of how the home is performing. EVIDENCE: The Registered Provider of the home carries out monthly visits in accordance with Regulation 26 of the National Minimum Standards. These are forwarded to the CSCI. At this present time, formal feedback from residents, relatives and visiting health professionals is not sought. This was discussed in detail with the Deputy Manager. The vast majority of the residents accommodated have a Power of Attorney to handle their finances. Should residents request a small purchase such as a bottle of shampoo or a new pair of slippers, an invoice is sent directly from the home to the person responsible. The home’s accident and incident records were viewed and found to be in order. Separate records are kept for residents, staff and visitors to the home. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 18 The home’s policy and procedures following any incident or accident to a resident has been amended. It is now the home’s procedure to inform relatives / next of kin within one hour of the incident occurring. The home has implemented new clinical procedures following a fall. This was found to be clear, concise and in line with clinical guidance and recommendations. All certificates for the maintenance of equipment are stored centrally and a running index maintained. Those seen include: liability insurance, the maintenance of lifts and hoists, electrical equipment, gas safety and electrical installation. The vast majority of fire doors within the home are fitted with automatic door closures, however some remain outstanding. The home is aware of the need to prioritise these in line with fire regulations. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 x 3 STAFFING Standard No Score 27 3 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x x 1 x 3 x 3 2 Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)(2) (a)(c)(d) Requirement Timescale for action 08/10/05 2. 3. OP16 OP33 4(1)(14) 24(1)(a) (b) 12(1)(a) 23(4)(a) 4. OP38 That all care plans are drawn up with the involvement of residents and / or their relatives [THIS IS OUTSTANDING FROM THE PREVIOUS INSPECTION REPORT] That the homes complaints 08/10/05 procedure is incorporated within the Service Users Guide. That the home introduce a 08/11/05 system for reviewing and improving the quality of care provided. That the outstanding fire doors 08/10/05 are fitted with automatic door closures. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP1 OP12 OP16 Good Practice Recommendations That a copy of the homes most recent inspection report is included within the the Service Users Guide. That additional hours for activities are considered. That the complaints procedure is produced and displayed in a more noticeable format e.g. larger print. H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 21 Queen Marys 4. OP28 That 50 of care staff are trained to NVQ level 2 by December 2005. Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Susssex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Queen Marys H59-H10 S14031 Queen Marys V237844 080805 Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!