Inspection on 23/01/06 for Queen`s Lodge,

This inspection was carried out on 23rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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`s Lodge, 12/09/07

Queen`s Lodge, 04/10/06

Queen`s Lodge, 20/09/05

Queen`s Lodge, 22/02/05

Queen`s Lodge, 29/09/04

Queen`s Lodge, 17/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Henry Nihill House

Birchwood

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

The Infirmary

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

CARE HOMES FOR OLDER PEOPLE Queen`s Lodge, 13 Queens Road Leytonstone London E11 1BA Lead Inspector Harun Rashid Unannounced Inspection 23rd January 2006 11:00 X10015.doc Version 1.40 Page 1 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 Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 2 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`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Queen`s Lodge, Address 13 Queens Road Leytonstone London E11 1BA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8558 6548 020 8558 6548 queens.lodge@btopenworld.com Mrs Miriam Binns Mr David Binns Mrs Miriam Binns Mr David Binns Care Home 16 Category(ies) of Learning disability (3), Old age, not falling registration, with number within any other category (13) of places Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Three (3) named service users may be admitted in the category Mental Health. The home can provide care for one (1) named service user with dementia needs. 20th September 2005 Date of last inspection Brief Description of the Service: Queens Lodge is a family-run residential care home offering care and support to sixteen older people. The home is situated in a residential area in Leytonstone, in the London Borough of Waltham Forest. The home is close to local amenities and shops are within walking distance. The home has easy access to public transport; Leytonstone underground station is within walking distance of the home. Some of the service users remain mentally alert and positive encouragement is given to all service users to maximise their interests and continue with activities they enjoy. The home is well known to the local community and has been the preferred choice of service users previously living close by who were familiar with the home. Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on a weekday morning on 23/1/06. The Inspector spoke to four members of staff including the registered manager and the proprietors. The Inspector also spoke to seven service users and a relative. They all expressed their satisfaction with the standards of care provided. 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`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 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 the following standard(s): 3 and 6 The management carries out pre-admission assessment of needs prior to making a new admission. The home does not provide intermediate care. EVIDENCE: The management always ensures that no service user moves into the home without having had his/her needs assessed. The proprietor(s) of the home always carry out pre-admission assessment prior to any new admission. Both proprietors/registered manager are qualified and completed their RMA courses and have been managing the home for over 20 years. The Inspector was satisfied from the examination of care files that newly admitted service users’ assessment of needs were carried out prior to their admission into the home. The home does not provide intermediate care. Therefore, the sixth standard is not applicable to this service. Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 8 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 the following standard(s): 7 and 8 All service users have care plans which were reviewed on a monthly basis. The home demonstrates that service users health and personal care needs are adequately met. EVIDENCE: From the examination of care plans it was clear that those were generated from comprehensive assessments undertaken by care managers/health professionals. For service users, who are self-funded, care plans were developed from comprehensive assessments carried out by the home. Daily records and staff interview confirmed that staff were able to implement care plans on a day-to-day basis. The registered manager promotes and maintains service users’ health and ensures their access to health care services to meet assessed needs of the service users. Staff escort service users to all medical appointments for example; G.P and dental. Occasionally health professionals visit service users in the home if requested by the service users. Currently a Community Psychiatric Nurse visits a service user who experiences poor mental health problem. Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 12,13,14 and 15 The management arranges social activities for service users. Staff encourage and welcome relatives and friends to visit service users. Service users receive a wholesome, appealing and balanced diet in a relaxed manner. EVIDENCE: The management takes responsibility to organise individual and group activities for service users. Service users are encouraged to join Dial-a-Ride and undertake shopping trips. In July 2005, the home had arranged a tea party for service users and an entertainer conducted a music programme for the service users. Service users family and friends are welcomed in to the home. At the time of the inspection three of the service users family members visited the home. Relatives informed the Inspector that they always feel welcomed by staff. A volume of praise was received- both written and verbal- from relatives. The home goes to great lengths to promote easy access for service users to benefit from positive community links such as outings/trips to places of interest for example; garden centres, theatre and church. The home encourage service users to bring their personal possessions with them, the extent of which is agreed prior to the admission. Information Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 10 regarding advocacy services for example, Age Concern is provided to service users and their relatives. From the observation of the lunch time meal and the examination of weekly menus it was clear that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements. The weekly menus offer choices of at least two main meals at each mealtime. The Proprietors advised the Inspector that if any service user does not like either meal then an alternative choice of meal is provided. Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 16 and 18 The complaint policy and procedures of the home were made available to all relevant parties. The Adult protection policy and procedure contain sufficient guidance for staff to enable them to protect service users. EVIDENCE: The home provides a simple and clear complaint policy and procedures for service users, their family members and for other relevant parties. The home maintains a complaint book, which was available for inspection. However, the Inspector was advised that the home has not received any complaint since last inspection. Staff of Queen’s Lodge attended Adult protection training. The Adult protection policy and procedure contain sufficient guidance for staff to enable them to protect service users from abuse. The Registered managers understand their responsibilities to refer staff who harms service users in their care to the Protection Of Vulnerable Adults (POVA) list. Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 19 and 26 The home is suitable for its stated purpose. It is safe and well maintained. The home is clean, hygienic and free from offensive odour. EVIDENCE: The layout of the home, which is a converted domestic dwelling with accommodation and facilities across five floors, is only suitable for service users who are not wheelchair users and who are relatively mobile (with assistance) and this is reflected in the home’s Statement of Purpose. Risk assessments are in evidence for all service users in relation to their dependency needs and the constraints of the physical environment. The home has a stair lift. Registered persons are recommended to consider how adaptations to the building can be made to provide older people with ‘a home for life’ in view of increasing dependency and mobility needs. All bedrooms have door locks and keys are provided if desired, and all bedrooms viewed have a lockable drawer for service users to keep valuables Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 13 and personal belongings. Service users bedrooms were personalised with family pictures and personal belongings. Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 14 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The service provides training for staff development. However, the management must ensure that 50 of their care staff completes their NVQ level 2 qualifications in care. The management to provide staff training on mental health awareness. EVIDENCE: Currently there are 10 care staff (full time and part time) employed in the home, in addition to the registered manager/proprietors who are usually available in the premises. At the time of the inspection the staff rota showed that three staff were on duty on the morning shift in addition to the registered manager/proprietors. All staff have a clear job description, which clarify their roles and responsibilities. The Inspector was advised that 6 members of staff completed their NVQ level 2 training in care in 2005 but unfortunately two of them left the service. As a result the home currently has 4 qualified members of staff (who have completed their NVQ level 2 in care and waiting for their certificates). The management informed that they will ensure that other members of staff commence their NVQ level 2 training in care in 2006. The registered manager must ensure that 50 of care staff complete their NVQ level two qualifications in care as required by National Minimum Standards (NMS). This standard will be monitored at the next inspection. Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 15 The home operates an equal opportunity policy for recruitment of staff. The jobs are advertised in the local paper/job centre. The registered manager obtains two reference letters and carries out all relevant checks including the CRB disclosures before employing any new staff. Copies of CRB checks and reference letters were available for inspection. The home showed a ‘Workforce Training and Development’ chart which outlined the training programmes for the 2005/06. All staff attended adult protection, dementia awareness training and a further training on dementia arranged with the Alzheimer Society in October 2005. However, it was required that the management must provide staff training on Mental Health awareness as the home currently accommodates 3 elderly service users with mental health issues. Following the recommendation of the previous inspection report, the management has obtained videos, worksheets and booklets from MIND on mental health awareness and care. The management is now in a process to conduct in-house training. This training to be completed by 30.6.06 Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 16 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 There is effective leadership; guidance and direction to staff to ensure service users assessed needs are met. The home ensures staff and service users health, safety and welfare. EVIDENCE: The Registered managers (also proprietors) manage the home on a day-to-day basis. Both are available in the premises most of the time for guidance and support to staff and service users. Both registered managers and proprietors completed their Registered Manager’s Award. Mrs. Binns previously worked with Social Services and has been managing the home for the last 20 years. Both proprietors are qualified and competent to run the care home and meet its stated purpose. The home obtains ‘Residents and Relatives satisfaction survey questionnaires’ on a periodic basis. The service users satisfaction questionnaires were Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 17 published and made available for the relevant parties. The evidence was shown to the Inspector. Service users financial interests were safeguarded and there were procedures in place. The Inspector was advised that Court of Protection manage seven service users’ finances and five of the service users finances are managed by their family members. One service user cash her pension credit at a local post office, a member of staff escorts her to the post office and assists her with the financial management. This information was recorded in service users files and professionals involved were consulted. Placing authorities social workers checks service users financial records during the review meetings. Members of staff interviewed informed the inspector that regular staff supervision took place with their supervisors. Minutes of supervision were available for inspection. All staff have opportunities to attend staff meetings. The management ensures safe working practice for health, safety and welfare of both staff and service users. Staff receive training in areas such as moving and handling, food hygiene, fire safety, medication administration and infection control. Risk assessments are undertaken for service users as required and there is a written statement of policy and arrangements for maintaining safe working practices. The management carried out the fire risk assessment of the premises. Records showed that all equipment was checked on a regular basis. The home has a valid insurance cover against the loss or damage. Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 18 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 3 Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES 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 OP28 Regulation 18 Requirement The registered manager must ensure that 50 of their care staff complete their NVQ level 2 qualifications in care by 2005. This was due to be completed by 31/12/05. (This will be assessed at the next inspection). The registered manager must 30/06/06 provide staff training on mental health awareness. Timescale for action 31/12/06 2. OP30 18 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. Refer to Standard OP19 Good Practice Recommendations The management to consider how adaptations to the building can be made to provide older people with a home for life in view of increasing dependency and mobility needs. Queen`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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`s Lodge, DS0000007224.V280087.R01.S.doc Version 5.1 Page 21 - 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. 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