Inspection on 17/09/07 for Queens Park Nursing Home

This inspection was carried out on 17th September 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 Park Nursing Home 30/04/07

Queens Park Nursing Home 18/09/06

Queens Park Nursing Home 09/02/06

Queens Park Nursing Home 23/05/05

Queens Park Nursing Home 02/11/04

Queens Park Nursing Home 10/05/04

Queens Park Nursing Home 09/02/04

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

CARE HOMES FOR OLDER PEOPLE Queens Park Nursing Home 37 Queen`s Park Parade Kingsthorpe Northampton Northants NN2 6LP Lead Inspector Stephanie Vaughan Key Unannounced Inspection 17th September 2007 08:15 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 Park Nursing Home DS0000012635.V347414.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 Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queens Park Nursing Home Address 37 Queen`s Park Parade Kingsthorpe Northampton Northants NN2 6LP 01604 719982 01604 718696 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) Dr Ramalingam Mudaliar Mr Daljit Singh Poone Nigel McGill Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (26), Terminally ill over 65 years of age (26) Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th April 2007 Brief Description of the Service: Queens Park is a home registered to provide care for people over 65 years of age, with a diagnosis of Dementia or Mental Disorder. The home has accommodation for up to 26 Service Users, mostly being provided in shared rooms. The accommodation is located over three floors, which are accessible by a passenger lift. The home has a large sitting room and a dining room and there is a quiet area for residents to receive their visitors in private. The home would benefit from some redecoration and refurbishment. The home is close to local amenities such as shops and bus stops. The provider advertises the availability of the Commission for Social Care Inspection reports to residents and their representatives in the home.Staff receive an individual copy. Information about the fees were provided during the inspection, these currently range form £385:00 per week, for residents funded by the Local Authority and £430.00 per week with extra charges for chiropody, hairdressing, newspapers, personal and items toiletries. Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to this statutory inspection, a period of four hours were spent in preparation. This comprised reviewing previous inspection reports, associated requirements and recommendations; the service history, risk assessment and other documentation. The Annual Quality Assessment has not been returned in time for the inspection and no residents comment cards were received. Since the last inspection the Commission have received two concerns about the home and these are addressed within the main body of the report. There have been no allegations of abuse or Safeguarding Adults referrals. The Commission have a focus on Equality and Diversity and issues relating to this are included in the main body of the report. This site visit to the home was conducted over a period of seven and a half hours during which the inspector made observations and spoke to residents and staff. However the communication ability of the residents is limited, in these circumstance observations are used to inform the inspection process. A limited tour of the premises was conducted which involved viewing the communal areas and a selection of the private accommodation. Case tracking is the method used during inspection where of a sample of three residents were selected and all aspects of their care and experiences reviewed, including individual plans of care and associated documentation. The Acting Manager was present during this visit and one of the partners was present for a short period. The current weekly fees range from £385:00 for residents funded by their local authority to £430:00 for privately funded residents with extra charges for chiropody, hairdressing, newspapers, personal and items toiletries. What the service does well: Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 6 The staff make sure that they have the right information about how the residents needs to be looked after before they come to live in the home. This means that they know that they will be able to care for them properly. Residents have up to date contracts in place, which contain the right information. Residents are able to make choices in their daily lives such as how to spend their time and the clothes that they wear. The staff make sure that residents individual needs are catered for and that residents from other countries have access to food and activities that relate to their country of origin. The standard of the food is good, it is home cooked and residents said that they enjoyed it. The home has a complaints policy, which is displayed in the home and complaints are investigated properly. Residents say that they feel safe living at the home and that the staff are nice to them. The staff know about the residents past life and are able to talk to them about their interests and families. There is a good range of regular activities in the home and residents can keep in touch with their families and friends. There is a nice garden area with furniture, which is safe for residents to use. There are the right amount of properly trained staff working in the home to make sure that the residents are looked after properly. The management make sure that new staff have the right checks before they start working in the home. What has improved since the last inspection? Each resident has a plan of care, which sets out how they need to be cared for. These now contain more information about the resident’s needs and wishes. Residents now have the right information in place to help prevent falls and falls form the bed. The Plans of Care now contain information to help staff make sure that residents do not loose or misplace the things that they need, such as spectacles and hearing aids. Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 7 The plans of care are checked regularly to make sure that they still have the right information. Residents and their representatives are able to say what they feel about what is written in the plan. Health care has also improved, the resident’s health is checked on a regular basis and if necessary the staff make sure that residents see the right doctors and specialists. Residents now have the right assessments done to make sure that they are safe and that they are supported to manage their behaviour. Improvements have been made to the way that medicines are managed this means residents get their medication safely. The home has now got screening for use when residents are moved with the hoist in the sitting room. The residents bedrooms are being redecorated, the dining room and kitchen floors have bee deep cleaned. New armchairs have been put in the sitting room and the lift door has been replaced. The Acting Manager has applied to become the Registered Manager for the home. Improvements have been made to the way that resident’s money is cared for. There is now a separate safe for this use and the right records are kept. The home makes sure that the right safety checks are done and that staff have the right training. No hazards were identified. What they could do better: Information about the home needs to be improved to make sure that people have the right information about the home and are able to make decisions and choices. This information also needs to be easy for people to read, produced in large print and be available in other languages and formats. The staff need to make sure that they record more information about the choices that residents make in their daily lives. Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 8 Menus need to be discussed with residents to make sure that they truly reflect the preferences of residents and that there is real choice available at all mealtimes. The management need to make sure that they write a letter to tell a person who has made a complaint what they have done about it. The management need to make some improvement to the environment such as replacement carpets to one of the bedrooms, the hall, stairs and sitting room. They also need to make sure that residents have the right furniture and fittings in their bedrooms when ever possible. Quality assurance needs to be further developed so that resident’s views are sought about how the service can be improved. Regular staff supervision needs to be done to check that staff are doing their jobs properly. 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 Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 9 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 Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 10 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): 1, 2, & 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of appropriate, up to date and accurate information about the service means that existing and prospective residents and their representatives do not have the right information to enable them to make informed decisions about the home. EVIDENCE: A Requirement was made at the last inspection the Statement of Purpose and Service Users Guide to be reviewed, to ensure that people who use the service have up to date and accurate information about the service. The Service continues to have a combined document entitled the ‘Residents Information Handbook’ this contains some of the information that is required for the Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 11 Statement of Purpose and some of the information that is required for the Service Users Guide. However there are significant pieces of information that have been omitted from the specification of both documents. The current document is dated December 2005 & 2006 and continues to have information that is out of date such as the details of the previous Registered Manager who has left employment at the home, the position is currently vacant. This Requirement has therefore not been met. The Statement of Purpose needs to be a separate document, which complies with the criteria specified in Schedule 1 of the National Minimum Standards. The Service Users Guide needs to comply with the criteria set out in Standard 1 of the National Minimum Standards, be written in plain English, available in other languages and formats such as large print and pictorial formats for residents who may not be able to read. Individual plans of care evidenced that residents have appropriate contracts in place, which have recently been reviewed. There have been no new admissions to the home since the last inspection. However individual plans of care evidenced that existing residents had received a comprehensive preadmission assessment to ensure that the service was able to meet their needs prior to admission. Te service does not provide intermediate care. Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. Residents have individual plans of care, which indicate that they are treated as individuals and that their health care needs are fully met. EVIDENCE: Each resident has an individual plans of care developed from their preadmission assessment. The standard of individual plans of care continues to improve. A further review is being conducted to ensure that the plans contain more detailed instruction to staff about the resident’s individual heath personal and social care needs. Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 13 Following a Requirement made at the last inspection all residents now have meaningful risk assessments for falls, falls form the bed and use of bedrails. These are based on current best practice. Following a Requirement made at the last inspection individual plans of care now contain instruction to staff about how the residents are to be supported with the use of equipment such as spectacles and hearing aids to reduce the risk of misplacement and loss. There is evidence that residents or their representatives are now involved in the care planning process and review. The management of healthcare also continues to improve. Individual plans of care evidenced that health care is becoming more individualised. Residents have care plans in place for their management of their oral care. The management of pressure ulcer prevention is good there are no residents with pressure ulcers at the home at present. Residents have appropriate risk assessments in place for the prevention of pressure ulcers and appropriate pressure relieving equipment is available. Residents are also regularly weighed and assessed for their nutritional risks. Following a Requirement made at the last inspection the individual plans of care now evidence that residents at risk are appropriately referred to external specialist services such as the Dietician, Continence Advisory Service and Audiology Service. Following a Requirement made at the last inspection Residents have appropriate risk assessments and care plans for the management of their psychological needs including the management of challenging behaviour. Residents are registered with a General Practitioner and have access to a range of other health care professionals such as Dentists, Podiatrists, Physiotherapists, opticians and hospital services. Medication systems were reviewed and found to be in good order. One Requirement was made as a result of the last key inspection regarding the homes medication systems. On this occasion there was evidence to demonstrate that there is now an accurate record of medication received, used and disposed of to ensure an appropriate audit trail. An additional inspection has also been conducted by a Commission for Social Care Inspection Pharmacist Inspector and three further Requirements were made. There is now evidence that Medication Administration Records are complete and accurately maintained including a record of the exact amount given when a variable dose is prescribed. There is also evidence that medication is now administered from containers labelled by the pharmacy and Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 14 that medication, such as eye drops are not used when they have exceeded the recommended expiry date. Improvements have been made to the way that privacy and dignity are managed in the home. Following a Requirement made at the last inspection the service have obtained appropriate portable screening for use in the communal areas when residents are being hoisted. There was one occasion during the inspection when this was not used and the Acting Manager addressed this with staff at the time. Appropriate laundry services are provided to ensure that residents are able to wear their own clothes at all times. All of the residents appeared clean and some were well presented. However others appeared dishevelled and many of the women were without tights or stockings. Through discussion with the staff it was established that residents are able to choose the clothing that they wear on a daily basis and are also able to make choices about whether or not they wish to access hairdressing services. At present these choices are not consistently recorded as they are made. The Acting Manager is mindful of the need to ensure that resident’s choices are recorded in the daily records to demonstrate compliance with the Mental Capacity Act. Staff were seen to relate well to residents and to use their preferred form of address. Residents were able to confirm that the staff were nice to them. Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 15 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. Social activities and meals are both well managed, are creative and provide daily variation and interest for residents living in the home. EVIDENCE: Through observations made and a review of individual plans of care it was established that routines are flexible in the home. Residents are consulted about the times that they rise and retire to bed and these are recorded in the care plan. Residents are able to move about within the home and to make choices about where to spend their time. Each resident has a detailed life history, which is used by staff to converse with residents about their earlier life and to develop activities that reflect their previous interests. Individual plans of care demonstrate that residents have access to regular activities within the home such as bingo, card games, Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 16 reminiscence therapies and music, including karaoke. Residents are also able to go on occasional outings with staff. The home has a dedicated activities coordinator who plans and runs the activities, a weekly activities programme is published. Residents were observed to be enjoying the activities provided. Residents are able to maintain links with their families and friends. Visiting times are flexible and residents can receive their visitors in private should they wish to do so. Residents are supported to maintain their faith thorough visits from the local church representatives and the provision of Holy Communion. Residents are supported to access the local community either by visiting relatives at home or shopping trips. Individual plans of care provide some evidence that residents are supported to maintain their autonomy and choice wherever possible. Following a Recommendation made at the last inspection polices and procedures have been developed to promote resident’s equality and diversity. Most of the residents are white British, however the ethnicity of other residents is reflected within the activities programme and the menus. The management are aware of the requirements of the Mental Capacity Act and have obtained a detailed assessment to enable the capacity of residents to be assessed. Guidance has been sought form the appropriate authorities regarding the management of a situation where a resident was deemed to lack capacity, this has been documented and the right action has been taken to address the situation. Individual plans of care evidenced that residents have access to a balanced and nutritious diet. Food is prepared in the home and appears to be of a good standard. Both the breakfast and lunchtime service were viewed. Breakfast comprised a choice of cereals and bread and butter. Lunchtime service comprised chicken casserole, stuffing, cauliflower and swede. A fish alternative was available however none of the residents had chosen this option. There was a choice of strawberry cheesecake or yoghurt for desert. Hot drinks were available at regular intervals throughout the day and fresh fruit and snacks were also available. All meals were well presented and of adequate proportion. Residents were able to confirm satisfaction with the food provided at the home. Residents requiring assistance were supported in an unhurried way and with sensitivity; food for residents requiring soft diets was appropriately processed and served. Appropriate food hygiene practices were evident. Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 17 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. There is a robust complaints procedure and good staff awareness and attitudes regarding the safeguarding adults so that residents felt safe and were protected. EVIDENCE: There is an appropriate complaints policy in place and this is displayed in the home. The management are mindful of the need to ensure that this is kept under review and reflects the changes to the Commission for Social Care Inspection contact details and function. Information about the complaints process is also included in the Residents Handbook. The management keep a record of all complaints received, the investigation and the outcome and there was evidence that the complaint raised during the last inspection had been appropriately managed. There have been two concerns raised about this service since the last inspection. In one of these there was evidence that this had been appropriately investigated, however whilst there was no evidence to Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 18 demonstrate that the service had acted inappropriately the service had agreed to take action to address the concerns raised. This had been communicated to the complainant by telephone only. There was no letter on file to demonstrate that the outcome had been notified in writing to the complainant. One further concern has been raised regarding an administrative dispute between the Registered Provider and a Provider of Energy. This is currently in the hands of the provider’s solicitor and further information is to be submitted to the Commission for Social Care Inspection. There have been no Safeguarding Adults allegations, residents confirmed that they felt safe living at the home. The service has received a copy of the recently published Local Authority Guidelines and training is scheduled for the near future. Staff spoken to were aware of their responsibilities in protecting residents from abuse. Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 19 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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment is adequate however further improvements should be made to ensure that residents have a comfortable and pleasant environment is in which to live. EVIDENCE: Queens Park Nursing Home is registered to provide nursing care for 26 residents. The home was registered in 1995 prior to the introduction of the National Minimum Standards in 2002. As a pre-existing home it continues to provide the same communal space, in the form of one sitting room and a Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 20 dining room. However a small quiet room has recently been made available on the first floor. Since the last inspection the dining and kitchen floors have been deep cleaned and new armchairs have been obtained for the sitting room. Residents are able to bring their own items of furniture into the home such as their own armchairs. The lift door has been replaced. There are two single bedrooms and the remaining twelve bedrooms are double. Bedrooms vary in size and in some cases space is limited which enables only basic furnishings and fittings to be provided. However most rooms have washbasins and reasonable access to bathroom facilities. Bedrooms are currently being redecorated and double rooms have appropriate screening in place. There is some evidence that residents are able to personalise their bedrooms however not all of the residents have chosen to do this. The grounds are safe, well maintained and accessible to residents. CCTV cameras are in place for the security of the premises however these do not compromise the privacy of residents. The premises are well lit, ventilated and heated. There are sufficient supplies of hot water. The premises are generally free from offensive odour, however carpets throughout are stained and worn. Management confirmed that carpets are regularly cleaned however the home would benefit form carpets in the communal areas and one bedroom being replaced. Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 21 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, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service employs appropriate numbers of inducted and trained staff to ensure that the resident’s needs are appropriately met. EVIDENCE: Individual plans of care demonstrate that the dependency levels of residents are regularly assessed. This information is used to calculate staffing levels. There is a staff duty rota, which evidences that staffing levels are good, the home currently cares for 21 residents. There is always a Registered Nurse on duty and there are sufficient care staff on all shifts. Nursing and care staff are supported by an activities coordinator, domestic and catering staff during the daytime shifts. Staff were seen to relate well to residents and to have a good understanding of their needs and preferences. Residents and staff spoken to were able to confirm that staffing levels were good. Staff files evidence appropriate recruitment practices. The management have introduced a new checklist to ensure that recruitment is managed effectively and efficiently. Staff files evidenced appropriate recruitment practices, two Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 22 references are obtained and appropriate clearances prior to the commencement of employment. A staff-training matrix has been developed to manage staff training. There is evidence that new staff have appropriate induction training and that other mandatory training is kept up to date. Recent training includes Basic Food Hygiene, Fire Safety, First Aid, Safe Administration of Medication, Risk Assessment, Mental Capacity, Management of Pressure and Movement and Handling. Further training is scheduled for the near future to include Safeguarding Adults, Infection Control, Dementia, Challenging Behaviour, Dignity in Care and Care Planning. Staff whose first language in not English continue to be offered support and training. Five staff have recently commenced National Vocational Qualification in Care level 2, it is estimated that this will enable 60 of care staff to have achieved this level of qualification. Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 23 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, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s interests are enhanced through the home being run in an organised manner, which adequately promotes their health and safety. EVIDENCE: The acting manager is a Registered Nurse, is currently undertaking training in the National Vocational Qualification level 4 in Care and Management and is also seeking registration with the Commission for Social Care Inspection. Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 24 There is evidence that the service continues to improve under the direction of the Acting Manager. Residents and staff were able to confirm that the Acting Manager was approachable and supportive. Appropriate Quality Assurance polices are in place, however progress in this area is slow. Since the last inspection there has been an audit of the individual plans of care, including risk assessments and nursing staff monitor the Medication Administration Records. However there have been no recent satisfaction surveys circulated to residents or their representatives. Arrangements for the safe storage of resident’s money have recently been reviewed. Money is now stored in a separate safe; residents have individual wallets, accurate records of receipt, expenditure, associated receipts and a balance bought forward. Records of two of the resident’s case tracked were reviewed and found to be in good order; records corresponded with the remaining balance. Following a recommendation made at the last inspection systems have been developed to enable staff appraisal to be commenced. However there are as yet no arrangements in place to enable staff supervision to be conducted. The Acting Manager has agreed to develop this in the near future. A limited tour of the premises was conducted, no hazards were identified and appropriate safety equipment was in place such as radiator guards. Since the last inspection a fire inspection has been conducted and some recommendations have been made, these are currently being implemented by the management. Fire records indicate appropriate checks are conducted and recorded. Records also indicate recent Portable Appliance Testing. The Acting Manager confirmed that the central heating and boiler had recently been serviced and the certificate has yet to be received. Staff receive appropriate and timely training to ensure that the health and safety of residents. Meaningful risk assessments are now in place and are regular reviewed. Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 25 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 2 3 3 X X 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 X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation Schedule 1 Requirement The Statement of Purpose and Service Users Guide must be reviewed to ensure that existing and prospective residents have up to date and accurate information. Outstanding from 01/07/07 Timescale for action 30/10/07 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 2. 3. 4. Refer to Standard OP1 OP8 OP15 OP16 Good Practice Recommendations The Service Users Guide should be developed to ensure that it is accessible to all. Daily records should evidence that residents are able to exercise choice in their daily lives Residents should be further consulted about the menus to ensure that they are able to exercise real choice at mealtimes. Management need to ensure that they provide a written DS0000012635.V347414.R01.S.doc Version 5.2 Page 27 Queens Park Nursing Home 5. 6. 7. 8. OP19 OP26 OP33 OP36 response to complainants, following complaint investigations, in line with their internal policy. A review of the environment should be conducted to ensure that wherever possible the home complies with the criteria set out in the National Minimum Standards. The management should replace the existing carpets in one of the identified bedrooms and the hall, stairs, and sitting room Residents satisfaction surveys should be conducted to ensure that residents are consulted about their views and that developments are in line with those views. Formal staff supervision should be implemented as specified in the National Minimum Standards. Queens Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Park Nursing Home DS0000012635.V347414.R01.S.doc Version 5.2 Page 29 - 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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