Inspection on 14/07/04 for Queens Care Centre

Care Home For Older PeopleQueens Residential Nursing HomeMillard Lane Maltby Rotherham South Yorkshire S66 7NAUnannounced Inspection14th July 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Queens Residential Nursing Home Address Millard Lane, Maltby, Rotherham, South Yorkshire, S66 7NA Email address Name of registered provider(s)/company (if applicable) Z.A.K. HealthCare Limited Name of registered manager (if applicable) Post Vacant Type of registration Care Home No. of places registered (if applicable) 40 Tel No: 01709 818181 Fax No: 01709 817409*Category(ies) of registration, with (number of places) Old age, not falling within any other category (40) Registration number C070000226 Date first registered 31st July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 24th May 2003 YES NO 24/ 03/04 If Yes refer to Part CQueens Residential Nursing HomePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 314th July 2004 09:00 am Ian HallID Code074214Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMs J HarrisonQueens Residential Nursing HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementQueens Residential Nursing HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Queens Residential Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Queens Residential Nursing HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Queens Care Centre is situated in Maltby within a short walking distance of all local amenities. It is a purpose built home with accommodation situated on two floors, the first floor being accessed by a shaft lift. 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). The home is attached to a Health Centre from which the Registered Person operates his GP practice. There are two service users lounge areas, which both accommodate dining areas and a kitchenette. Additional day space is provided for service users who wish to smoke. The home accommodates older people 65 years and older that require 24 hour personal and nursing or personal care.Queens Residential Nursing HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This unannounced inspection in the year 2004/2005 has looked at a range of the National Minimum Standards applicable to this home. The announced inspection later this year will cover these standards. This may result in a number of standards being inspected twice in the inspection year 2004/2005. This is considered good practice, and consistent with a professional approach to registration. The findings of this inspection are that staff at continues to provide a high standard of care for all service users at the home. The homes manager and her team have worked hard to implement changes required to meet the National Minimum Standards. A number of minor additions and changes remain to be completed. Choice of Home (Standards 1-6) 4 of the 5 standards assessed were met 1 did not apply The Service Users Guide/Statement of Purpose is available and provided for all service users or/and their advocate. The home provides a contract for service users that contained the required information. Full needs assessments were undertaken, but service users and their representatives were not always fully included in assessments. Trial visits to the home took place. Health and Personal Care (Standards 7-11) 3 of the 5 standards assessed was met Care plans require additional information. Service users and their representatives were not fully involved with them. Assistance with service users care and care plans did not reflect the care or service provided. Refusal of personal care by service users requires detailed entry within the records. Difficult patterns of behaviour require detailed entry and recording including discussions or information passed to next of kin. Daily records were not maintained consistently. Visits by professionals allied to medicine and the outcome are not consistently discussed with next of kin. Monthly updates of reviews, both formal, and written do not consistently take place. Service users spoken to all expressed satisfaction with the personal and healthcare provided. Medication storage was satisfactory. Staff interacted very well with service users, being cheerful and respectful. Daily Life and Social Activities (Standards 12-15) 1 of the 4 standards assessed was met Service users said that daily routines were flexible and varied. The home offered a range of activities but not on a regular basis. Less able service users lacked one to one input toQueens Residential Nursing HomePage 6 access activities. Religious needs were catered for. The home did not employ an activities co-ordinator. Food served was well balanced and wholesome. Complaints and Protection (Standards 16-18) All of the 3 standards assessed was met The home had a complaints procedure in place and service users spoken to state that they would know how to make a complaint if necessary. The Adult Protection Policy was in the process of revision to include Whistle Blowing and the Department of Health No Secrets guidance. Environment (Standards 19-26) 3 of the 8 standards assessed was met The location and layout of the home was suitable for the service user group. Furnishings and decoration were generally in good condition. The homes gardens were secure. The height of the hedge does limit both the view and light to the home/garden there is discarded equipment and over grown areas that require removal from the area Staffing (Standards 27-30) 0 of the 3 standards assessed were met Some staff were undertaking NVQ2 training and the manager had yet to begin NVQ4 in Care and Management. Mandatory training had commenced. The induction programme had been revised. Management and Administration (Standards 31-38) 2 of the 8 standards assessed were met Service users meetings were irregular and there was no formal system of consultation such as service users surveys. Staff supervision and appraisal has commenced see comment within main body of report. Accidents to service users must be notified to next of kin.Queens Residential Nursing HomePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 14, 15, 17, schedule 3 OP7 The homes management must ensure that 31st each service user has a comprehensive plan of August care generated from a comprehensive 2004 assessment, reassessed at appropriate intervals to provide the basis for care given. This must be compiled with each service user and/or appropriate other person (next of kin) 2 14, 15, 17, schedule 3 OP7 The homes management must ensure that adequate daily records are maintained. These include care and service provided, evaluation of care and communication with service user, next of kin and relevant others. They must include events and incidents that affect the service users well-being. All staff must receive training in moving and handling, food handling and hygiene, and adult protection awareness All bedrooms must be fitted with two double sockets. 31st August 2004318OP3031st August 2004 31st August 2004423OP24Queens Residential Nursing HomePage 8 518OP36A formal supervision system must be 31st developed, and staff must receive supervision August at least 6 times a year. The homes owner 2004 must provide adequate numbers of suitably qualified staff (activities organiser/coordinator) to ensure that service users are provided with opportunities for stimulation through leisure and recreational activities both in and outside the home which suit their needs, preferences and capabilities.times each year. Staff meetings must be held more frequently. The homes owner must provide adequate numbers of suitably qualified staff (activities organiser/co-ordinator) to ensure that service users are provided with opportunities for stimulation through leisure and recreational activities both in and outside the home which suit their needs, preferences and capabilities. Staff meetings must be held more frequently. 31st August 2004612,13OP12714, 15, 17, schedule 3OP3The homes management must ensure that 31st each service user has a comprehensive plan of August care generated from a comprehensive 2004 assessment, reassessed at appropriate intervals to provide the basis for care given. This must be compiled with each service user and/or appropriate other person (next of kin)8 9 1017(1)a OP9 Schedule 3 23) 18(1)(a)(b) (c)(1)(2) OP27 OP30Ensure that medication record charts do not contain unexplained omissions. All bedrooms must be fitted with two double sockets. Ensure implementation of training programme and plan. Provide written plan containing details of course, dates and staff attending to CSCI. (1) The plan must be appropriate to the work they do (2) Suitable assistance, including time-off, for the purpose of obtaining qualifications appropriate to such work1st June 2004 1st June 2004 1st July 20041121OP32Implement regular staff meetings to improve communication and foster an open and inclusive working atmosphere. Provide written schedule of meetings to CSCI.1st July 2004Queens Residential Nursing HomePage 9 1225OP34Ensure that accounts/records are available for inspection to demonstrate both effective management and financial viability.31st August 2004Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 2 3 OP31 OP28 OP27 The registered manager achieves an NVQ 4 or equivalent qualification by 2005 Minimum 50 of staff achieve NVQ 2 by 2005 Review range of colour, style and sizes of uniform. The current range does little to identify staff, their role or responsibilities. This causes potentially confused service users and visitors to the home confusion.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No) NOQueens Residential Nursing HomePage 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The homes management must ensure that each service user has a comprehensive plan of care generated from a comprehensive assessment, reassessed at appropriate intervals to provide the basis for care given. This must be compiled with each service user and/or appropriate other person (next of kin) The homes management must ensure that adequate daily records are maintained. These include care and service provided, evaluation of care and communication with service user, 1st October next of kin and relevant others. They must 2004 include events and incidents that affect the service users well-being. Visits by next of kin or other visitors should be recorded in service users care plans. 3 17(1)a OP9 Ensure that medication record charts do not contain unexplained omissions. The homes owner must provide recreational and diversional activities for service users. Additional staff must be employed to plan, implement and facilitate these activities 1st September 2004 1st November 2004114,15,17, schedule 3OP31st November 2004214,15,17, schedule 3OP7412,13OP12Queens Residential Nursing HomePage 11 A record of meals chosen and provided must be maintained. 5 16 OP15 Menus to be reviewed in respect of number of times that soup and sandwiches appear on the menu The homes owner must ensure that the home is suitably furnished, decorated and maintained. Décor and curtains in toilet areas requires softening 7 23 OP21 All toilet/bathroom areas must have toilet roll holders fitted and lids fitted to the waste bins All bedrooms must be fitted with two double sockets. Furniture supplied must be in good repair. The source of the pungent odour in the identified bedrooms must be identified and the odour eradicated Lampshades must be replaced in lounge areas The homes owner must provide adequate numbers of staff to exercise their choice during unpaid meal times. The minimum staff numbers must be maintained at all times. 10 18(1)(2)(3) OP27 The homes owner must provide adequate numbers of suitably qualified staff (activities organiser/co-ordinator) to ensure that service users are provided with opportunities for stimulation through leisure and recreational activities both in and outside the home which suit their needs, preferences and capabilities and time each year.1st October 2004623OP191st January 20051st January 2005823OP241st January 2005823OP251st January 20051st January 2005Queens Residential Nursing HomePage 12 Ensure implementation of training programme and plan. Provide written plan containing details of course, dates and staff attending to CSCI. · 11 18 OP30 · The plan must be appropriate to the work they do Suitable assistance, including time-off, for the purpose of obtaining qualifications appropriate to such work1st January 2005All staff must receive training in moving and handling, food handling and hygiene, and adult protection awareness Implement regular staff meetings to improve 1st communication and foster an open and November inclusive working atmosphere. Provide written 2004 schedule of meetings to CSCI. The Registered manager must develop a quality assurance system Ensure that accounts/records are available for inspection to demonstrate both effective management and financial viability. Staff supervision files must be securely stored. The home owner must review infection control practice at the home in consultation with the infection control specialist · · OP38 · · · Staff hand washing/drying facilities Provide red dissolvo bags to lessen handling of foul linen Upgrade existing sluice provision Submit plan to provide additional sluice provision Review cleaning schedule and carpet cleaning methodology 1st January 2005 1st January 2005 1st January 2005 1st September 20041212OP3213OP331425, 38OP341524OP36Queens Residential Nursing HomePage 13 The home owner must review health and safety risk and undertake remedial actions · 15 13,16,23 OP38 · · Remove waste equipment from side of home Clean and equip sluice adequately Renew kitchen floor surface, the surface is damaged, temporary repair is a trip/slip risk and cannot be readily cleansed 1st January 2005RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 3 OP31 OP28 OP27 The registered manager achieves an NVQ 4 or equivalent qualification by 2005 Minimum 50 of staff achieve NVQ 2 by 2005 Review range of colour, style and sizes of uniform. The current range does little to identify staff, their role or responsibilities. This causes potentially confused service users and visitors to the home confusion.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Queens Residential Nursing HomePage 14 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES YES YES NO YES YES YES YES YES YES NO YES YES YES YES YES 9 7 X YES YES YES YES 20 10 14/07/04 O8.20 8.00Queens Residential Nursing HomePage 15 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Queens Residential Nursing HomePage 16 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 277 To (£) 362Any charges for extras If yes, please state what the extras are: Key findings/EvidenceYESHAIRDRESSING NEWSPAPERS trips out holidays Standard met? 3The home has developed a Statement of Purpose and Service User Guide, which the inspector examined this is available to service users or their next of kin.Queens Residential Nursing HomePage 17 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? Individual service users are provided with a contract specifying terms and conditions of residence and service provision.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 2 Key findings/Evidence Standard met? Care records needs assessment data was incomplete. This assessment must include a family and social history, along with likes, dislikes and preferences in the daily routine. From this incomplete assessment reflects in the care plan developed. A number of individual needs were not identified, other plans did not identify how daily living needs and activities are to be met. On admission all service users are assigned to a registered nurse who is required to undertake a full needs assessment of the service users physical and physiological needs. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. Key findings/Evidence Standard met? 3Specialist aids and equipment are available at the home, assessment by specialist practitioners and their advice is sought as required. The involvement of Specialist Practitioners has not been consistently communicated to next of kin. Examining records and talking to staff and service users provided the inspector with evidence that specialist professional advisors are accessed by staff at the home to assist them in providing care. Specialists frequently used were Dieticians, Physiotherapists and Community Psychiatric Nurses (CPN).Queens Residential Nursing HomePage 18 Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? Service users are invited to spend time whether part of or a whole day at the home prior to admission. This may be limited by the service users level of health or ability.Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The home does not provide intermediate care.Queens Residential Nursing HomePage 19 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? The inspector checked three care plans. They were limited in content in identified areas and a number did not clearly specify staff action needed to ensure that needs were met. There was limited record of family involvement within one of the three plans checked, and two of the three plans did not contain information relating to hobbies and interests. There was a lack of information when completing assessment tools for risk of falls, nutrition and weight monitoring for loss/gain. Activities were often not recorded nor visit of next of kin or significant others. The daily record/commentary was not being maintained consistently and comments lacked meaning or qualification. Statements such as appears confused requires qualification as to which area of consciousness is affected, whether confused to time, place or person.Queens Residential Nursing HomePage 20 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence 8 2 Standard met? 3All service users are registered with a G.P. of their choice. There was evidence that specialist health care workers were consulted and visited the home when aspects of care needs became complex. There was a range of assessment tools and risk assessments included in the care plans i.e. pressure damage, moving and handling, risk of falls and nutrition, which are needed to assist in effective care delivery. These documents were not consistently completed resulting in a lack of key information on occasion. Relatives were not consistently advised or updated about their loved ones care programme. Visiting practitioners provided professional support for dentistry, ophthalmic and chiropody services, or if able the service user is encouraged to visit the practice. Community nurses visited the home to provide nursing care to those service users that had been admitted for personal care only. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? The home has a policy for the safe administration and storage of medication, which the inspector saw. Samples of medication administration records were checked and these appeared to be generally complete. There were however a number of unexplained omissions. Records were kept of the receipt, administration and disposal of medication. Records of three monthly Pharmacist checks were seen. The home does not have photographs of all service users.Queens Residential Nursing HomePage 21 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? At the time of the inspection staff demonstrated understanding of dignity by ensuring residents received assistance with personal aspects of care, and making sure they were appropriately dressed with any aids they required e.g. glasses, hearing aids. Service users were free to spend whatever time they wished in their own room, and there were no restrictions on when to rise or retire. Staff were observed to knock on bedroom doors before entering, they promoted the privacy of residents and dealt with any personal matters in private. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? Staff on duty were able to describe their role in caring for a dying person. They clearly appreciated their role in providing support for the next of kin and each other. Policy and procedures were available for staff information.Queens Residential Nursing HomePage 22 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 2 Key findings/Evidence Standard met? The Registered Person formerly employed an activities organiser. Staff are involved in a number of fund raising activities, in their own time, to fund some outings for service users. The support for service users who would benefit from individual activities was limited. Activities that are conducted are limited to any spare time available to care staff. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 2 Key findings/Evidence Standard met? Families that were spoken to during the inspection considered that they felt welcome and could visit whenever they wished. Visits by next of kin or other visitors are not regularly recorded within the records maintained at the home. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? There are three service users that manage their own personal finances. The majority of service users have handed the responsibilities for managing their finances to their family. The home has a policy on access to records and service users were aware of this policyQueens Residential Nursing HomePage 23 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 2 Key findings/Evidence Standard met? The homes menu was checked and appeared to be overall varied however there appears to be reliance upon soup and sandwiches on occasion. There was a lack of records to evidence meals chosen or provided. Choices were offered, and staff said they had access to food stocks at all times to cater for service users needs. All of the service users spoken to say the food was good. Staff were seen offering assistance at mealtime to some service users in an appropriate manner. The meal was not rushed.Queens Residential Nursing HomePage 24 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence 3 X 2 X 1 X 100 3Standard met?The home has received three multi-faceted complaints during the last twelve months. The complainants have not been satisfied with the homes response or outcome. They had been passed to the CSCI (formerly NCSC) for further investigation. These matters have been satisfactorily resolved except that one complainant has failed to respond to the CSCI.Queens Residential Nursing HomePage 25 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? The home ensured that all service users legal and civic rights were respected and were given the opportunity to exercise their voting rights, most choose to use the postal vote.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Standard met? YES X 3The inspector saw the Adult Protection and Whistle Blowing Policies. Staff had received specific training on adult protection. Discussions with staff indicated that they were aware of issues around abuse and would report any suspected incidents of abuse.Queens Residential Nursing HomePage 26 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The home is situated in the centre of Maltby with easy access to local shops and amenities. The Registered Person does not employ a handyman. Extractor fans throughout the home were in need of cleaning and repair. Environmental Health inspection records were seen, and records of environmental risk assessments were seen. The woodwork and walls have suffered damage from wheelchairs and equipment being moved around the home. Wallpaper was torn and damaged. Carpet in corridor areas was observed to be tired and worn, the renewal of carpet in adjacent corridors emphasises the carpets deteriorating state. Repairs have been undertaken with pieces of wood. There has been ongoing redecoration and refurbishment including provision of new carpeting. There was no clear plan or strategy to demonstrate a timetable and commitment to completing the necessary works. There is no separate hairdressing facility.Queens Residential Nursing HomePage 27 Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? The home meets the special requirements for communal dining and lounge areas. There is an additional smoking lounge area..Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 2 Key findings/Evidence Standard met? Twenty-one of the rooms have the benefit of an en-suite wash hand basin and toilet. The home has more than the number of bathrooms and toilets than this standard requires. A number of toilet/bathroom areas lacked toilet roll holders, waste bin lids were missing. The areas were not welcoming or comfortable, lacking curtains and decorative features. The home has separate sluicing facilities away from bathrooms and toilets. Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? Levels of nursing aids and equipment appeared sufficient to meet the care needs of the current service users. When assessing service users for moving and handling and pressure relieving equipment the home seeks advice from the relevant specialist advisors to ensure the most appropriate equipment is provided. Additional moving and handling equipment has been provided including a heavy-duty hoist.Queens Residential Nursing HomePage 28 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence NO YES NO 17 8 4 0 Standard met? 3 35 012 0 2 4The home has had four double rooms. The size of single rooms ranged between 11.4sq.m to 13.7 sq.m. Double rooms are all 17.5sq.m. This exceeds the standard required for an existing home.Queens Residential Nursing HomePage 29 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 2 Key findings/Evidence Standard met? A number of bedrooms were inspected and found to have all the appropriate furniture with the exception of a table to sit at, and not all rooms had two easy chairs. However service users that were spoken to consider their room to be furnished as they wished and had no complaints. All bedroom doors were fitted with a lock of which some service users had their own key. One bedroom had two double sockets the others had one double socket and one single socket. The bedrooms seen were well personalised. Two bedrooms had a pungent and persistent odour. Staff reported that attempts to clean the room and carpet had been unsuccessful. Identified items of bedroom furniture were in need of repair or replacement. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? All bedrooms had radiators that could be individually adjusted. Bedrooms were found to be at an ambient temperature although the weather conditions were good. Hot water outlets were fitted with pre-set valves and those tested confirmed that hot water was discharged at 43°C. One toilet and one bathroom had some exposed pipe work. Lampshades had not been replaced in the main lounges following redecoration.Queens Residential Nursing HomePage 30 Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 2 Key findings/Evidence Standard met? The laundry was fitted with an industrial washer, which had a sluice cycle, used mainly for bed linen, a smaller washer used for personal items of clothing. There were two industrial driers. A health and safety notice was displayed and C.O.S.H.H. information was also displayed. Domestic/housekeeping staff had not received training to prevent spread of infection. The laundry was in need of cleaning, there was a substantial accumulation of dust, fluff and debris behind the washing machines. The area is small was unclean, cluttered and smelled. The walls were dirty, the wall and floor coverings were in need of repair /replacement. There are inadequate staff hand washing and hand drying facilities in the sluice and throughout the home. Disposable paper towels liquid hand soap and dispensers must be provided. Hot air drying machines inhibit thorough drying of hands. This risk must be assessed and remedial steps taken. The homes owner must consult the infection control specialist to ensure that the home maintains safe and effective hand washing facilities. Consideration must be given to replacement of the slop hopper open sluice with a mechanical system. A single sluice on the ground floor is barely adequate provisionQueens Residential Nursing HomePage 31 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 15 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence 11 2 X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 868 X X 1687 20 10 Standard met? 2The duty rota was examined, and a number of shifts were requiring cover. Staff are not paid for meal breaks, members of staff left the home during their break time as they are entitled to do so. The homes owner must ensure that safe levels of staff are maintained at all times. Additional staff must be provided to allow staff to leave the home during their unpaid break periods.Queens Residential Nursing HomePage 32 The home had recently recruited bank staff, and is attempting to recruit further staff. Staff said they worked well together to cover shifts. There were shifts that lacked a full complement of staff. There was no consistency in staff uniform and appearance. This was confusing for the inspector, visitors to the home, and service users. Staff confirmed that they had to purchase their own uniform from their own monies. The home does not provide staff with uniform. Staff were therefore free to select the colour and style of their individual choice. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence 3 7 Standard met? 2The homes owner was aware of the requirement to have 50 of staff trained to N.V.Q.2 by 2005 and was addressing this issue. Staff were enthusiastic about NVQ training.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 9 Key findings/Evidence Standard met? The inspector was unable to examine staff files. The staff spoken with said they had to pay for their CRB checks and had applied personally.Queens Residential Nursing HomePage 33 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2 Key findings/Evidence Standard met? The manager has developed a staff-training plan, which employs the services of an accredited training organisation. Records were seen to evidence that external training had been planned and budgeted for. This training met National Training Organisation targets. Not all of the staff spoken to said they had received Food Hygiene, Fire and Moving and Handling training. Catering, Laundry and domestic staff had not received a suitable induction or training programme. They needed training in Moving and Handling, Health & Safety at Work, Control of Substances Hazardous to Health, (COSHH), MRSA/Spread of Infection and FireQueens Residential Nursing HomePage 34 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The acting manager has not achieved N.V.Q. level 4 in management; he is a qualified nurse with experience in the elderly care field. The manager application form has not been received; therefore the home is currently without a registered manager. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 2 Key findings/Evidence Standard met? Staff spoken to during the inspection did not feel that they were fully involved in the day-today operations of the home or given the opportunity to contribute to improving standards.Queens Residential Nursing HomePage 35 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? There was no quality system available for inspection.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 2 Key findings/Evidence Standard met? These were not available for inspection.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Standard met? 3 X X XThe nurse in charge was unaware of any service users being subject to power of attorney. Families of service users were responsible for the control of personal monies with the exception of three service users who controlled their own monies. The home had no responsibility as an appointee for any service user. Each service user has a locked drawer provided in their bedroom for the safe keeping of any money or valuables that they wish to keep in their possession. However staff discouraged them from keeping large amounts of money and advised relatives to limit the amount kept in rooms, or use the facility of the homes safe.Queens Residential Nursing HomePage 36 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Standard met? A formal supervision system is in place. These confidential records were not stored securely. Staff did not receive a personal record of their supervision. Staff said that staff meetings occur infrequently.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? All records were kept in the managers office and were maintained in accordance with the Data Protection Act 1998. The home has an Access to Records Policy and service users indicated to the inspector that they were aware of their rights to access.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? Maintenance records of equipment were inspected and all equipment had been serviced in accordance with manufactures requirements. All moving and handling equipment was also examined in accordance with L.O.L.E.R. Fire log records showed that the fire alarm system was tested weekly staff had not received twice-yearly fire prevention training.Queens Residential Nursing HomePage 37 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceRegulatory Inspector Second Inspector Regulation Manager DateIan Hall Ann MicklethwaiteSignature Signature SignaturePublic reports It should be noted that all CSCI inspection reports are public documents. Queens Residential Nursing Home Page 38 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 14th July 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleQueens Residential Nursing HomePage 39 Action taken by the CSCI in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 2nd September 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was requiredAction plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Queens Residential Nursing HomePage 40 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I, Mrs Parveen Khan of Queens Care Home, confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the 14th July 2004 and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I, Mrs Parveen Khan of Queens Care Home, am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the 14th July 2004 for the following reasons: The unannounced inspection took place at a time when a bank nurse who did not know the admin information. A considerable number of points had already been dealt with and proof provided in March 2004.Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Queens Residential Nursing HomePage 41 - 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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