Inspection on 20/10/05 for Queens Care Centre

This inspection was carried out on 20th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Queens Care Centre 06/01/09

Queens Care Centre 15/01/07

Queens Care Centre 13/05/05

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

The Grove Waltham

Carentan House

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 7NA Lead Inspector Ian Hall Unannounced Inspection 20th October 2005 01:25 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 Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 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. Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Queens Care Centre Address Millard Lane Maltby Rotherham South Yorkshire S66 7NA 01709 818181 01709 769756 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) Z.A.K. HealthCare Limited Christopher Stephen Nicholson Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 2003 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 DS0000003086.V256217.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6.5 hours and was the second of the cycle of inspections for the year 2005/6 and followed a risk assessment carried out with the CSCI risk assessment tool. The focus of the inspection was to meet both service users and visitors to the home to gain an insight into daily life for residents. The officer met with members of the on duty staff team and toured the site. Three residents care files were “case tracked” and the associated records checked. 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. Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 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 Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 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): 1, 2, 3, 4, 5, 6. Examination of case files and discussions with relatives and residents demonstrate their involvement in choosing to live at Queens Care Centre. During the officers discussion with management it was evident that the needs of existing residents are considered throughout the assessment process before a decision to admit another resident is taken. EVIDENCE: Residents and their advocates confirmed that they had discussed the care and service provision before admission to Queens Care Centre. The case files examined contained individual copies of care assessments, care plans and written contracts that stated both terms and conditions of residence. Intermediate care is not provided at the home, however respite care is provided by negotiation. Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 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, 8, 9, 10. Staff were focussed upon meeting the needs of both residents and their families. Relatives were observed to visit freely and continue to assist with care of their loved ones. Family members spoken to confirm their involvement in the planning and provision of social, physical and psychological care and provision. The home facilitates access to the whole range of health care professionals and health care facilities. Staff were observed to interact with residents skilfully, professionally and with obvious empathy for each individual. EVIDENCE: The officer inspected care records of 3 residents; they contained individual “needs” assessments with plans of “care” for staff to follow and meet each individuals needs. These records were correctly maintained; they described how each resident responded to the care package and any necessary changes that were made. These were monitored at regular intervals; some plans had been amended within the timescale in response to changing needs. None of the residents was responsible for their own medication although this facility is available. Staff were observed administering medications and providing appropriate support to residents. Service users and visitors stressed that staff were always keen and willing to help them. Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 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, 15. The manager and his team have worked hard to build links with the local community. An activities programme has been organised to meet service users needs. Visitors are welcome to visit at any reasonable time making them feel welcome. Service users are offered a choice of meals each day, and the menus are well balanced to meet service users nutritional needs. EVIDENCE: There were numerous visitors to the home throughout the day. They confirmed that they were able to visit at any reasonable time, with shift workers visit at any other time by appointment. Well-behaved pets were able to visit be arrangement. The home employs an activities co-ordinator. Activities were organised on either a one to one or small group basis. Residents were observed to be reading, listening to music and watching television. None of the residents currently leave the home unless accompanied by members of their family or staff. Nourishing fluids were readily available throughout the day. There was a choice of midday meal, staff was observed to encourage and assist with meals as needed. Mealtimes were unhurried with extra portions available as required. Relatives were pleased to be to assist their loved ones with meals. Specialist Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 Page 10 diets are available for those requiring this service. The dietician has assisted with compiling the menu. Service users are at liberty to take their meals in their own rooms. Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 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, 18. The complaints procedure is implemented correctly and effectively, which ensures that complaints are taken seriously and satisfactory outcomes are achieved. Staff spoken to were confident and competent to respond to concerns or complaints effectively. They had been trained in the protection of vulnerable adults, and are aware of actions to take if they had any concerns. EVIDENCE: Residents and staff stated that they had no concerns or complaints about care or services provided. They confirmed that they had regular and easy access to the homes owners and manager and that any small points raised were dealt with promptly. The home maintains a Complaints Book in which it records all formal complaints and the action taken in response. 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 demonstrating staff training in abuse prevention recently. Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 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, 20, 21, 22, 23, 24, 25, 26. The home both appeared clean and smelled fresh. The homes owners and team works hard to both maintain and improve the resident’s environment. EVIDENCE: The homeowners continue to redecorate and refurbish the home in line with their business plan. Individual bedrooms have been redecorated, re-carpeted and refurbished since the last inspection. This work is ongoing. Several bedrooms were visited; all appeared comfortably furnished and decorated. A number of residents and their families had taken the opportunity to personalise their space with personal effects and memorabilia. Toilets and bathrooms were readily accessible and equipped with aids and adaptations as required. Service users and family members spoken with were very satisfied with the building and its cleanliness. The corridors are wide and are fitted with handrails. The home has pest control and disposal of clinical waste systems that are functioning effectively. The home has records of training provided of staff training in health and safety issues. Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 Page 13 The window frames and doors are in need of maintenance and repair. Several have deteriorated substantially and are in need of urgent attention. Lighting provided throughout service user occupied areas requires updating and must be domestic in character rather than the present fluorescent fitments present in many areas. The gardens are in need of maintenance and boundary fencing requires repair and /or replacement. The inspector and manager discussed the suitability of the current layout and garden design. The current rockeries present a potential risk to service users who may injure themselves. Staff when in this area always accompanies Service users. Mr Nicholson has agreed to undertake a risk assessment and discuss the findings with the home’s owner. Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 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, 30. Over 50 of the care workers have achieved NVQ training. The staff team are keen to learn, develop their skills and knowledge base, this reflects within the personal care provision. The home operates appropriate recruitment policies to ensure that service users are protected from unsuitable staff. EVIDENCE: The staff group without exception were well motivated and enthusiastic about their work. They confirmed that not only were they well supported in their work but actively encouraged and supported to develop personally. Staff has undertaken statutory training and updates i.e. moving and handling, fire prevention etc, and are involved in national vocational qualification training and medication administration training. Personnel files contain all the required documents including a record of formal interviews, references, CRB checks, equal opportunities forms and contracts of employment. 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 their employment. The Manager is to be commended for his positive ongoing commitment to training and developing his staff team. Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 Page 15 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): The home is well organised and managed with all statutory servicing and checks complete. The management teams enthusiasm and positive approach to elder care has clearly influenced the whole team and benefited the service users. He home seeks feedback about the quality of its services from service users, relatives and staff. This information is being used to compile an annual Development Plan. A statement from the proprietor’s accountant confirms the financial viability of the home. The home’s manager has compiled a detailed risk assessment and health & safety policy/procedures to protect service users and staff. EVIDENCE: Visitors to the home stated that they had ready and easy access to the homes owners and management and that they felt confident in them. Mr Nicholson the registered manager is a qualified nurse with a wide range of skills and Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 Page 16 experience in elderly care. Staff expressed confidence in his management ability. He is ably supported by his deputy manager Ms N Starrs who is currently studying for her managers award. Staff stated here was always a senior member of staff on duty at the home with advice and support readily available. Responsibilities were shared between senior members of the team. Risk assessments had been completed and were reviewed regularly. The manager arranges meetings to monitor the quality of its services. Staff meetings are held every two months, service user meetings every six months and an annual survey of relatives. Dr Khan retains responsibility for administering the financial systems and managing the budgets for the home. His accountant has confirmed the financial viability of the home. Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 Page 17 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 2 2 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X 3 3 3 Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? no 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 OP19 Regulation 13(4) 23(2) Requirement Timescale for action 01/04/06 2. OP19 23 The registered person shall ensure that : a) all parts of the home to which the service users have access are so far as reasonably practicable free from hazards to their safety c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. 23(b) The registered person shall having regard to the number and needs of the service users : ensure that the premesis to be used as the care home are kept in a good state of repair both internally and externally. 23(o) external grounds which are suitable for, and safe for use by service usersare provided and appropriately maintained. Fencing panels are damaged, missing or in need of maintenance. Window frames and doors, internal and external are in need of repair, replacement or/and maintenance. The registered person shall 01/04/06 DS0000003086.V256217.R01.S.doc Version 5.0 Queens Care Centre Page 19 ensure that : . Lighting at the home must be domestic in character, corridor and lounge lighting is currently provided by fluorescent fitments. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Queens Care Centre DS0000003086.V256217.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster 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. 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