Inspection on 29/11/07 for Queens Oak Care Centre

This inspection was carried out on 29th November 2007.

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 Oak Care Centre 18/11/08

Queens Oak Care Centre 12/05/06

Queens Oak Care Centre 01/12/05

Queens Oak Care Centre 15/07/05

Queens Oak Care Centre 04/02/05

Queens Oak Care Centre 19/08/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Queens Oak Care Centre 64-72 Queens Road Peckham London SE15 2EP Lead Inspector Ornella Cavuoto Unannounced Inspection 10:00 29 November & 4 December 2007 th th 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 Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 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 Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queens Oak Care Centre Address 64-72 Queens Road Peckham London SE15 2EP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7277 9283 020 7277 9263 karen.brown@excelcareholdings .com Lancewood Ltd Lorna Esmay Thomas Care Home 88 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (54) of places Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To include no more than 34 service users with Dementia at any one time. The service users at Queen`s Oak Care Centre can be approached as to whether they would like to move to another bedroom, though must be moved at their own will. 1st March 2007 Date of last inspection Brief Description of the Service: Queens Oak Care Centre is a care home with nursing for older people, built in 2001. It is owned by Excel Care, a large care provider with homes in London and other parts of the country. There are four floors and care for service users suffering from dementia is provided on two of them. Care for service users with physical frailty and for service users requiring nursing care are provided on the other two floors. The home is near Peckham town centre, close to shops and all community amenities. There are train and bus routes near the home and some parking space in front of it. All bedrooms are single and all but four are fully en-suite. Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over two days. The registered manager was present for both days and was very helpful in facilitating the inspection process. Prior to the inspection twenty relatives’ surveys were sent out of which five were returned. Five service users were spoken to as well as three members of the care staff team and one of the activities co-ordinators. Other inspection methods that were used included observation, inspection of care records and a partial tour of the premises. What the service does well: Generally feedback from service users and relatives in surveys received back were positive about the home and support received from staff. Comments from service users included; ‘ The girls are very nice here’, ‘food is alright’, ‘I like it here’. Relatives said; ‘It is very family orientated, the staff on Mum’s floor are like our ‘extended’ family’, ‘The staff are very friendly, answer questions’. ‘I am delighted with the care my mother receives, also the respect shown to her’. Service users ‘ needs have been assessed prior to being admitted to the home to ensure the home is able to meet their needs. Care plans are generally well detailed to make sure service users’ needs are addressed and these have been regularly reviewed. Service users’ health care needs have been well met. Service users are treated respectfully and their privacy and dignity is maintained. Service users have been supported to maintain contact with family and friends, relatives are kept informed of any changes in respect to service users. Service users are able to be part of the local community, they are supported to go out locally to the shops and the pub and entertainers and representatives from local churches come into the home. Where appropriate service users are able to manage their own finances and can bring in personal belongings into the home. Meals provided at the home are well balanced and nutritious with good portions provided. Complaints are thoroughly investigated by the home and appropriate action is taken to address any concerns. Service users are protected from abuse by ensuring staff are trained to recognise signs of abuse and any allegations made in relation to the home are investigated. The home is generally well maintained. The home is adequately staffed and staff have been supported to achieve relevant qualifications and to undertake additional training to ensure service users’ needs can be met. Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 6 Overall the home is well managed and the home has systems in place to monitor that standards of the home are maintained and the home is run in the best interests of service users by taking into account their views. 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. The summary of this inspection report can be made available in other formats on request. Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 &4 Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users who have moved into the home have had their needs fully assessed to ensure that their needs can be met. The home has taken measures to ensure that the environment of the home is suitable for all service users living at the home. EVIDENCE: Eight personal files were looked at during the inspection, two files from each floor; care for service users suffering from dementia is provided on two of them. Care for service users with physical frailty and for service users requiring nursing care are provided on the other two floors. There was evidence on the files that full needs assessments had been obtained prior to service users being admitted to the home and also the home had completed its own comprehensive pre- admission assessment. Subject to a previous requirement that the home should ensure environmental adaptations are put in place to orientate service users with dementia this was Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 9 met. An expert report had been obtained and the home had largely addressed the recommendations specified. Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9&10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans in place for service users generally did cover in sufficient detail health, personal care and social care needs but changing needs of individuals had not always been clearly reflected and falls risk assessments had not all been fully completed. Service users’ health care needs had been addressed. Staff had not always adhered to medication policies and procedures to ensure service users were protected. Service users considered they had been treated respectfully and their privacy and dignity was maintained. EVIDENCE: The format of the care plans used by the home are not very accessible particularly for service users and relatives due to the volume of information included. However, it was reported by the regional manager that work is being undertaken by the provider to develop a more simplified care plan. Care plans that were seen were detailed with all areas of need as required by National Minimum Standards (NMS) generally being well addressed although information regarding service users’ sexuality, religious and cultural needs was lacking. It is advised that more attention is paid to these areas when drawing up care plans with service users. In addition, it was identified that not all care Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 11 plans had been signed either by service users themselves or a relative or representative where appropriate to indicate their involvement and understanding of care plans that had been completed. Furthermore, it was noted that although care plans had been reviewed, monthly changes in individual service users’ needs that were identified had not always been updated within the care plans, for example for one service user where changes in their nutritional needs had occurred these had not been reflected in their care plan whilst for another service user a deterioration in their mental health had not been addressed. General risk assessments that identified risks presented by individual service users’ needs were in place. Risk assessments that in particular addressed falls and manual handling assessments were also on files but not all these had been fully completed (See Requirements & Recommendations). It was evident from service users’ files that their individual health needs had been addressed. Risk assessments had been completed in respect to pressure sores, continence and nutritional needs that had been reviewed monthly. Also, service users had been weighed monthly. Weekly reports in respect to incidence of pressure sores and weight loss are drawn up to enable the registered manager to closely monitor these areas. Visits from health professionals were recorded on a separate sheet within personal files and demonstrated there had been liaison with GP, opticians, dentists, podiatry, community psychiatric nurses (CPN) and consultant psychiatrists. Concerns about the management of medication had been identified at the last two inspections. At the last random inspection held some improvements in this area had been made with two of three requirements being met. However, a requirement that staff needed to adhere to proper procedures for recording of medication administration was still an issue as it was seen that staff were not always recording when administering medication. At this inspection, a random sample of medication records was checked from three of the four medication trolleys in use at the home. A number of errors were identified where staff had not signed the medication record sheets although it was evident that medication had been administered. As a result the requirement previously stated still stands. Furthermore, for one service user it was identified that the instructions for the administration of one of their medications had initially been written incorrectly on the medication record sheets. This was corrected but rather than being re –written clearly the original entry was altered potentially causing confusion and further errors being made. Both qualified nursing staff and carers administer medication. The three care staff spoken to all stated they had received training on medication from a pharmacist. The registered manager reported that a very detailed medication work booklet developed by the provider was in the process of being used to train staff and to date ten staff had completed this. The booklet was seen and was very comprehensive covering areas as specified within common induction standards (See Requirements). Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 12 Generally interaction observed between service users and staff was warm and respectful and overall service users spoken to were positive about staff and confirmed they always knocked before entering their rooms ensuring their privacy and dignity was maintained. Issues of privacy and dignity had also been addressed within care plans. Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities had been developed to engage service users although more effort is required to ensure everyone are included in activities provided. Service users had been supported to maintain contact with family & friends and to exercise choice and control in their lives where appropriate. Meals provided to service users were nutritious and well balanced. EVIDENCE: At the past two inspections it was assessed that service users had not been given sufficient opportunities to engage in activities inside and outside the home. At this inspection it was identified that considerable progress in this area had been made. The home had employed a second activities co-ordinator since the last inspection with each of the co-ordinators working twenty hours a weekly at opposite times from each other to maximise time spent with service users. Both the co-ordinators had undertaken reminiscence training at the Pump House and had done a course on dementia provided by the Alzheimer’s Society (For further details see Standard 30) and a course on depression. Further training had also been organised to support the co-ordinators to be able to provide activities that would effectively engage service users with dementia and the home was in the process of setting up a sensory room. One of the activities co-ordinators was spoken to and they explained how they Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 14 would use reminiscence with service users on a one to one basis. They also provided evidence that service users had been consulted about their preferences on activities and photographs were seen of a recent trip organised for some of the service users to see the Christmas lights in Central London and when service users from another home locally had come to visit service users at the home. The activities co-ordinator reported how service users where appropriate are taken out to the pub, shopping locally and a trip to a museum in the area had also been organised. A weekly activities schedule was in place that is regularly reviewed and included activities such as bingo, baking, musical sessions amongst others. During the inspection activities observed being undertaken with service users included exercises using balls and a musical therapy session in which staff from St Christopher’s Hospice had come into the home and engaged service users in playing a range of musical instruments. The session was very positive with service users clearly enjoying it. All service users had a social care diary in which activities they had been involved in were recorded. A sample of these were checked and it was noted that whilst those service users with dementia had regularly been involved in a range of activities, those service users on the nursing and residential care floors had not been involved in as many structured activities. The activities coordinator did report that activities were held on different floors of the home to give service users as much opportunity as others to become involved. However, records indicated that more attention was being given to service users with dementia and whilst this was positive it is advised that efforts are made to ensure all service users within the home are given encouragement and opportunities to engage in activities that are provided (See Recommendations). There was evidence from files and also from speaking to service users that they had been supported to maintain contact with family and friends. Relatives’ surveys received also confirmed that they regularly visited the home. There are no restrictions on visiting. The home had also assisted service users to maintain contact with the local community by providing church services within the home and also by taking services out to the local shops, pub and to other places of interest. In respect to service users being able to exercise choice and control it was observed that service users were able to do as they wished and could spend time in their room alone or with others. They had been encouraged to bring in their personal possessions with them, which was evident in bedrooms that were seen. Where appropriate service users are also able to manage their own finances. Overall service users spoken to were happy with the food provided at the home. A lunchtime was observed with different floors being checked and this was relaxed and unhurried. The meal was nutritious, well- balanced and ample portions were given. A choice of meals was available. The menu was varied and there was an additional menu in place to cater for individuals’ specific Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 15 cultural needs. Staff supported service users that required assistance to eat in a respectful and appropriate manner. Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints had been recorded and fully investigated. Service users had been protected from abuse. EVIDENCE: The majority of surveys received from relatives indicated that they were aware of how to make a complaint about the home if required. In respect to service users, they either did not have any complaints about the home or as one service user reported they had expressed their dissatisfactions with the home to the manager and they were clear about their rights to complain. Yet, two service users stated they were not aware of the home’s complaints policy or who to talk to if they were not happy. It was noted that a copy of the home’s statement of purpose and service user guide had been placed in service users’ rooms in which information about the policy was included. A copy of the complaints policy had also been placed on notice boards on each floor for service users’ information. However, this was written in small print and was quite lengthy. It is advised that this is placed in bigger print and is written more simply to make it more accessible to service users (See Recommendations). The home’s complaints log was seen and the home had received fifteen complaints since the last random inspection was held, three of which the registered manager reported as having been substantiated. These mainly related to staffs’ attitude and to issues relating to standards of care provided at the home. Records kept in relation to the complaints demonstrated that all the Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 17 concerns had been thoroughly investigated and appropriate action had been taken. In respect to adult protection, the registered manager reported that all staff had undertaken training in respect to protection of vulnerable adults (POVA) apart from those staff had only recently been recruited. The three care staff that were spoken all confirmed they had completed training in this area and had knowledge of different types of abuse and action to be taken if abuse was identified or suspected. There was also evidence that POVA training had been completed within staff files checked. There had been one investigation that had been undertaken in relation to the home since the last random inspection. There was evidence of a comprehensive report that had been drawn up by the home in response to the allegations that related to the care received by a service user and that the home had been neglectful. The outcome of the investigation found allegations against the home to be unsubstantiated. Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was well maintained and provided a safe environment for service users. Service users’ bedrooms meet their needs. Not all areas of the home were free from offensive odours EVIDENCE: The home was purpose built in 2001 and is well sited in terms of transport and local facilities. Previous inspections had raised concerns as to whether the ground floor was suitable for dementia care. However, as mentioned in respect to Standard 4 the home had obtained expert advice about this, which on the whole identified the ground floor space to be appropriate for people with dementia and the levels of security to be appropriate. Some recommendations were made about improving the area to enable service users to engage with the space more effectively and these had either been addressed or were in the process of being dealt with, for example the registered manager reported replacement furnishings to provide a more homely feeling were to be purchased. Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 19 A previous requirement that there should be two comfortable chairs in each bedroom had been addressed by the home. There was evidence of a form in service users’ personal files that service users or relatives where appropriate had signed to indicate whether or not they wanted an extra lounge chair in their rooms. Bedrooms seen were comfortable and well furnished. Generally the home was clean. However, on both days that the inspection was held there was a notable odour of urine on the ground floor. This was not detectable on the other floors but the home must take measures to ensure all areas of the home are free from offensive odours (See Requirements). Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has sufficient levels of staff to meet service users’ needs. Staff had been supported to achieve a relevant qualification. The home’s recruitment procedures and practices protect service users. Staff are trained to ensure they can meet service users’ needs effectively. EVIDENCE: It was evident through observation on both days that the inspection was held that there was sufficient staff on duty on all the floors to ensure that needs of service users were met. A previous requirement that staff hours must allow for a handover between shifts had been met. A staff member spoken to, confirmed that the handover period was included as part of their shifts. It was reported by the care manager that twenty four of forty one care staff employed had completed a National Vocational Qualification (NVQ) Level 2, two had obtained NVQ Level 3 and one had a degree in Health and Social Care. A further three care staff had been referred to start a NVQ Level 2. Bank staff were not accounted for but the home had met the target specified within National Minimum Standards (NMS) that 50 of staff must have completed a NVQ. Care staff spoken to, had either completed or were in the process of undertaking a NVQ Level 2 or 3. In respect to recruitment, a sample of staff files belonging to individuals that had been recruited since the last inspection was checked. These were all in Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 21 order with all the necessary information and checks required by regulation having been obtained including two references and appropriate identification documents. All the staff had an Enhanced Criminal Record Bureau (ECRB) check apart from two that had commenced working at the home based on a check being made against the Protection of Vulnerable Adults (POVA) list that includes the names of any individuals deemed to be unsuitable to work with vulnerable adults. This was done as an interim check whilst waiting for confirmation of their ECRB checks that had been applied for. In addition, for these two staff the home had completed a risk assessment that was on their individual staff files that had addressed the need for both staff to be supervised which is required under POVA guidelines if staff do not have a full ECRB check in place. There was evidence from staff files that care staff had completed an induction that met with Skills for Care specifications. Subject to a previous requirement, there was an annual training and development plan in place. It was evident from this and from staff files that mandatory training had been completed, for example manual handling had been updated annually as required. In respect to specific training to ensure service users’ needs could be effectively met by staff the home was arranging for all care staff to complete a distant learning course via Croydon college in Dementia Awareness; six were in the process of completing the course and a further eight were due to commence the course in December. Care staff spoken to, confirmed they were undertaking the long distant course and it was helping them to increase their understanding of working with service users with dementia. In addition to this, approximately sixteen of the care staff had undertaken a course ‘Dancing with Dementia’ arranged by the Alzheimer’s Society that was aimed at raising awareness and to equip staff with knowledge to work with people with dementia effectively. A further course had been arranged for January 2008. Other training courses organised included one that looks at the Mental Capacity Act and further long distant courses were being looked at in relation to Equality and Diversity. Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35&38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run and managed and is run in the best interests of service users with systems in place to monitor the quality of service being provided. Service users’ financial interests are safeguarded. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The registered manager who has overall responsibility for the management of the home is a qualified nurse who has many years of experience working with frail elderly people and people with dementia. They also have a management qualification and are presently working towards achieving the Gold Standards Framework for End of Life Care in conjunction with St Christopher’s Hospice. There is also a Care Manager who has responsibility for all clinical matters. A previous requirement that management hours to properly run the home needed to be calculated in order to ensure sufficient management hours were Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 23 provided and that an assessment and calculation should be sent to CSCI had been addressed. A letter was sent to CSCI outlining the number of management hours in place and these were sufficient for the effective running of the home. It was also evident from the inspection that the home was being well managed. In respect to quality assurance evidence was seen of a customer satisfaction survey that had been completed with service users, relatives and professionals for 2007. In addition, the home had a detailed and comprehensive action plan in place that outlined action to be taken to address issues highlighted by service users from surveys completed as well as matters raised by CSCI inspections, internal audits carried out the provider, food hygiene and fire safety inspections amongst others. It was reported this report was reviewed and updated every two weeks to assess progress in areas. In addition to this as mentioned in respect to Standard 8 a weekly report is compiled to monitor service users’ weights and incidence of pressure sores. Care plans and medication are audited regularly and Head Office checks finances. Service users are allowed to manage their own finances but the home does also look after the finances for a number of service users living at the home. The home’s system for managing service users’ finances was checked and found to be robust with individual records being maintained and receipts for transactions kept. It was evident from records seen that the home had protected the health, safety and welfare of service users and staff. The home carries out monthly health and safety audits of the home. As mentioned in respect to Standard 33 the home also has a detailed action plan that includes measures to be taken to improve fire safety and food hygiene and to address any maintenance issues identified. There were up to date maintenance certificates in place for gas safety, portable appliances testing (PAT) and for fire equipment. Fire drills had been completed monthly and weekly tests of the fire alarm call points had been carried out. The home had also ensured that CSCI had been notified of incidents as required under regulation 37. Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 3 X X X X 3 X 2 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 X 3 X 3 X X 3 Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement The registered person must ensure that all care plans are signed either by service users themselves or a relative or a representative where appropriate to indicate their involvement and understanding of the care plan that is drawn up. The registered person must ensure that where changes in respect to service users’ needs are identified through monthly reviews that their care plans are updated to reflect these changes and to ensure their needs are fully being met and appropriate interventions are being taken The registered person must ensure that falls risk assessments are fully completed for all service users The registered person must ensure that staff adheres to proper procedures for recording of medication administration. (Previous timescales of 30/06/06 & 30/04/07 not met) The registered person must DS0000007045.V346974.R01.S.doc Timescale for action 31/05/08 2. OP7 15(2)(c)& (d) 31/05/08 3. OP7 15(1) 31/05/08 5. OP9 13(2) 31/05/08 6. OP9 13(2) 31/05/08 Page 26 Queens Oak Care Centre Version 5.2 7. OP26 16(2)(k) ensure that where required staff write instructions for the administration of medication correctly and clearly on medication record sheets. The registered person must 31/05/08 ensure that all areas of the home are kept free from offensive odours. 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 OP7 Good Practice Recommendations The registered person should try to ensure that more attention is paid to service users’ religious, cultural needs and also to how their needs will be addressed in respect to their sexuality. The registered person should try to ensure all service users are provided equal opportunities to be involved in activities provided in the home and for social interaction. The registered person should consider revising the home’s complaints policy that is placed on notice boards to be placed in larger print and written more simply to make it more accessible to service users. 2. 3. OP12 OP16 Queens Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Oak Care Centre DS0000007045.V346974.R01.S.doc Version 5.2 Page 28 - 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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