Inspection on 13/05/05 for Queens Care Centre

This inspection was carried out on 13th May 2005.

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

Queens Care Centre 06/01/09

Queens Care Centre 15/01/07

Queens Care Centre 20/10/05

Queens Care Centre 14/12/04

Queens Care Centre 14/07/04

Queens Care Centre 24/03/04

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Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE QUEENS CARE CENTRE MILLARD LANE MALTBY ROTHERHAM, SOUTH YORKSHIRE S66 7LZ Lead Inspector Gordon Chivers Unnanounced 13 May 2005 09:00. th 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. QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service QUEENS CARE CENTRE Address MILLARD LANE, MALTBY, ROTHERHAM, SOUTH YORKSHIRE, S66 7LZ 01709 769756 01709 769756 None Z. A. K. Healthcare Limited 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) Christopher Stephen Nicholson ARRC Care home only 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14-Dec-2004 Brief Description of the Service: Queens Care Centre is situated in Maltby within a short walking distance of all local amenities. The home is attached to a Health Centre from which the Registered Person operates his GP practice. The home accommodates older people that require 24 hour personal care. It is a purpose built home with accommodation situated on two floors, the first floor being accessed by a lift and staircases. All bedrooms are single occupancy with the exception of four double rooms, which at present have single occupancy and will remain so whilst occupied by the existing service users. There is an intention that in the future these rooms may be used for wheelchair users that need additional space (as opposed to double occupancy). There are two lounge areas, both of which accommodate dining areas and a kitchenette. Additional lounge space is provided on the first floor for service users who wish to smoke. There is a pleasant, sheltered garden/patio area in front of the building. QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 13 May 2005, starting at 9.00 a.m. and finishing at 4.30 p.m. The inspection included interviews in private with two service users, two relatives, three members of staff, the proprietor, and the manager. Other service users and staff were also spoken to during a tour of the premises. A sample of case files and personnel files and other documentation were examined. The inspector would like to thank the service users, staff and management for their welcome and cooperation during this inspection. What the service does well: What has improved since the last inspection? Visitors and staff all recognised the on-going improvements to the decoration and furnishings of the home. The manager has now attained the Registered Managers Award and three care staff have gained NVQ Level 2 in Care Parts of the home have been re-decorated and re-furbished and plans are in place to continue with this work. QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 Page 6 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. QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 Page 7 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 QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 Page 8 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) 3 Full assessments of need are undertaken to ensure that service users are placed appropriately and form the basis of a relevant care plan. EVIDENCE: A sample of the case files were examined. All contained full assessments of service user need, including a pre-admission assessment by the referring social worker, medical information, interests and preferences in ‘everyday’ life, and assessments of need and risk assessments developed over time by the staff. Staff and a relative confirmed that service users and relatives contribute directly to these assessments. These assessments form the basis of the care plans, which are in place for all service users. The files of two recently admitted service users did not contain all the personal information required or (in one case) a photograph of the service user. However, on the evidence of the other files it is reasonable to assume that these omissions will be rectified in due course. QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 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) 7,8,9,10 There is a comprehensive care plan for each service user, but not all care plans have been reviewed on a monthly basis. This may result in staff not having the relevant information to ensure care needs are appropriately met. Since the inspection the manager has implemented a system to ensure care plans are reviewed monthly, which will ensure staff have up to date information to meet service users care needs. The health needs of service users are constantly monitored and referred to appropriate health care professionals when necessary. The home’s medication procedures are complied with effectively, which ensures medication is managed safely to protect service users and staff. The one exception is that the medicine trolleys are not secured to the wall when not in use, resulting in unsecured storage Service users are treated in a respectful manner and their privacy is upheld. EVIDENCE: All of the case files examined contained full care plans based upon the assessments of need. In each case there was a plan of action of how the QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 Page 10 home would meet the identified need. There was evidence of service user and family involvement in this process. The daily record was relevant and maintained consistently. However, not all care plans have been reviewed on a regular monthly basis. This has now been rectified. The case files contained clear and up to date medical information about service users, including monitoring of weight and nutrition, contact between service users and medical professionals, the reason for referrals and the desired outcome of medical intervention. All service users are registered with a G.P. Visiting professionals included dentists, ophthalmists, chiropodists and community nurses. The home maintains a record of all accidents suffered by service users each month and what action was taken by staff as a result The home has a self-medication policy, but none of the current service users self medicate. The administration of medication was observed to be correct and competent. Samples of medication administration records were checked and these were complete. Records were kept of the receipt, administration and disposal of medication. All the staff who administer medication have undertaken accredited training. The medication is stored in a locked treatment room in either a locked metal cabinet fixed to the wall or in the trolleys used for direct administration. However, the trolleys are not secured to a wall when stationed in the treatment room. A local pharmacist inspects the home’s medication practice every three months, the most recent being in March 2005. The service users and relatives interviewed confirmed that staff treated them with respect. Staff were observed to knock on bedroom doors before entering, and they dealt with any personal matters in private. Staff demonstrated an understanding of dignity by ensuring residents received assistance with personal aspects of care, and making sure they were appropriately dressed. QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 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) 12,13,15 The home provides some organised activities, but possibly not enough to ensure that all service users are fully stimulated, and not in a way which relates to their assessed needs or care plans. Activities have been reviewed since the inspection and more have been organised based and service users social needs. Hopefully this will make day to day life more enjoyable and fulfilling for the service users. Visitors are welcome to visit the home at any reasonable time making them feel welcomed. Service users are offered a choice of meals each day, and the menus are well balanced and meet the nutritional needs of the service users. EVIDENCE: The home employs a part-time activities organiser for two hours on five mornings per week. Activities include outings and shopping. However, there was no evidence of a plan of activities based upon the assessed needs of service users, or records of how the activities contributed to meeting these needs. Some relatives considered there were insufficient activities to fully stimulate all the service users. The activity programme has now been increased and hopefully service users and relatives will see the benefits this will achieve. QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 Page 12 The homes menu was checked; every day there was a choice of two main courses and two teas. These choices changed from day to day. Service users could opt for something else if they did not like the choices on offer. Vegetables were included in the main meal every day. Records of special dietary requirements were kept in the kitchen. All of the service users spoken to said the food was good. Staff were observed to be offering assistance at mealtime to some service users in an appropriate manner. The dining areas of the two main lounges are well provided for. Service users are at liberty to take their meals in their rooms. QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 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) 16,18 The complaints procedure is implemented correctly and effectively, which ensures that complaints are taken seriously and satisfactory outcomes are achieved. Staff have been trained in the protection of vulnerable adults, and are aware of what action to take if they have any concerns in this respect, thus protecting service users from possible harm or abuse. EVIDENCE: The home maintains a Complaints Book in which it records all formal complaints and the action taken in response. There have been two complaints in the last twelve months, one of which was investigated by the manager and the other by Social Services. Both of these complaints have been partly substantiated, and one is still on-going in so far as the home is awaiting a response to its investigation and actions by the complainant. The home operates the joint Social Services/NHS/Police Protection of Vulnerable Adults policy and procedure. It also has a whistle-blowing policy. There are records of the staff having been trained in recognition and prevention of abuse by an external training agency over the last year. The staff interviewed confirmed that they had received this training and that they considered themselves to be fully aware of the issues and their importance. None of the staff interviewed had witnessed or heard of any incidence of possible in the home. QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 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 The home has been redecorated and refurbished to a good standard and further work is scheduled and so provides a clean and safe environment for service users. EVIDENCE: The proprietor has implemented an action plan for the redecoration and refurbishment of the home. The entrance area, corridors, lounges and bedrooms have been redecorated and refurbishment. The works are ongoing, particularly in the stairwells. Visitors and staff interviewed all commented upon the improvement, which has been achieved over the last eighteen months. All radiators have guards around them. The home is clean and there are no offensive odours, due in part to the installation of air fresheners fixed to the walls. The corridors are wide and have handrails. The smokers lounge on the top floor requires a new carpet and an ‘expelair’ device to prevent the smoke contaminating the adjacent bedrooms and corridor. The proprietor has in store on the premises new floor covering to replace the old and worn covering in the kitchen and food store. This work should be done as soon as possible. The home has pest control and disposal of clinical waste systems, QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 Page 15 which are functioning effectively. A report by the local authority Environmental Health department required improvements to the system for moving bags of dirty laundry about the home and the cleaning schedules for the kitchen. These requirements have subsequently been implemented. The home has records of staff training in health and safety issues. However, there is no legionella test certificate and no policy for the prevention of infection in place, although some staff are currently undertaking training in infection control. Since the inspection quotes for testing for Legionnaires are being obtained. QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 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) 28,29,30 The home is on course to having over half of its care staff suitably qualified by the end of 2005. The home operates appropriate recruitment policies which ensures that service users are protected from unsuitable staff. Training of staff is given a high priority and is well managed. EVIDENCE: The home currently employs twenty-one care staff of whom ten have attained NVQ level 2 qualification and a further eight are currently undertaking the course. This should ensure that the home meets the standard within the set time frame. The personnel files contain all the required documents including a record of formal interviews, references, CRB checks, equal opportunities forms and contracts. Staff interviewed confirmed that they could not commence work until the CRB checks had been received and that they undertook induction training over the first six weeks of employment. The manager has developed a training plan for all of the staff. This contains identified training needs, training planned and scheduled, training currently being undertaken and training completed. All new staff undertake an internal induction programme followed by a TOPPS induction and foundation course. The staff interviewed confirmed that the home’s management place a high priority upon training, and that staff are constantly engaged in are range of training courses. QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 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) 31,33,34,35,38 The manager has recently attained the Registered Managers Award, which will enable and support him to continue to run the home efficiently and constantly seek ways to make improvements. The home seeks feedback about the quality of its services from service users, relatives and staff and this information will be used to develop an annual Development Plan. A statement from the proprietor’s accountant confirms the financial viability of the home. Records of the administration of service users’ personal monies are kept appropriately ensuring the safe management of service users monies. The home’ equipment and infrastructure are regularly tested and serviced ensuring a safe environment for staff and service users. QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 Page 18 EVIDENCE: Mr Nicholson, the manager, is a qualified nurse with a wide range of skills and experience in elderly care. Staff interviewed expressed confidence in his management abilities. He has completed the Registered Managers Award course and is awaiting receipt of the certificate. Despite the requirement from the last inspection, the manager is still included within the staffing rota in breech of the agreement made by the proprietor with the CSCI. Since the inspection the proprietor has reviewed this situation and the managers hours are no longer included in the staff rota and will only cover a shift during holiday periods. The home arranges meetings by which to monitor the quality of its services. Staff meetings every two months, service user meetings every six months and an annual survey of relatives, although the response to latter was poor and the manager intends to change its format in the hope of making it more effective. The practice is to act immediately upon key issues arising from these meetings. However, the manager also accepts that issues arising from these meetings can contribute to an annual development plan for the home. The proprietor, Dr. Khan, retains the responsibility for administering the financial systems and managing the budgets for the home and his accountant has confirmed financial viability of the home. Some service users have their personal allowances administered by their families, the home undertakes this task for the remainder. The monies and the records of transactions are kept in locked box in a safe part of the home. Each transaction is witnessed by two members of staff, receipts are kept and occasional checks on the system and the balances are made by senior staff. There is no independent audit. The home keeps records of all the checks and maintenance undertaken by the respective authorities and contractors on the home’s equipment and infrastructure. The records refer to the passenger lift, hoists, gas supply, PAT, the call alarm system, the fire alarm system, fire equipment and regular fire drills. The manager has also undertaken his own risk assessment of the premises. QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 x 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 3 3 x x 3 QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 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. 2. 3. 4. Standard 9 19 19 19 Regulation 13 23 23 23 Requirement The medication trolleys should be secured to a wall in the treatment room when not in use. The new floor covering should be laid in the kitchen and food store A device for expelling the smoke from the smokers lounge should be fitted. A policy for the prevention of infection should be put in place, and a legionella test certificate should be achieved. Timescale for action 01/07/05 01/07/05 31/07/05 31/07/05 5. 6. 7. 8. 9. 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 3 Good Practice Recommendations Full personal information and a photograph of service users are entered into the case files as soon as possible. J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 Page 21 QUEENS CARE CENTRE 2. 3. 4. 28 33 35 The manager should complete the process of having at least 50 of staff qualified to NVQ level 2 by the end of 2005. The manager produces an annual Development Plan based upon key issues arising from the quality monitoring system. The records of service users personal allowances which the home administers are independently audited. QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster South Yorkshire DN4 5HZ 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 QUEENS CARE CENTRE J55-J07 S3086 Queens V185007 130515 Stage 4.doc Version 1.30 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. 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