Inspection on 30/06/05 for Queensberry Road

This inspection was carried out on 30th June 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

Queensberry Road 08/05/07

Queensberry Road 23/01/06

Queensberry Road 11/01/05

Queensberry Road 07/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Queensberry Road 22 Queensberry Road Kettering Northamptonshire NN15 7HL Lead Inspector Shiela Smith Unannounced Thursday, 30 June 2005 at 16.30 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Queensberry Road Address 22 Queensberry Road Kettering Northants NN15 7HL 01536 415201 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Royal Mencap Society Vacant CRH 5 Category(ies) of LD Learning Disability registration, with number of places Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11th January 2005 Brief Description of the Service: Queensbury Road is a home for up to 5 service users with learning disabilities. The home is owned and managed by Royal Mencap Society who have many years experience of providing care in residential settings. 22 Queensbury Road is situated amongst other houses, similar in age and design, close to local shops and accessible by public transport. The premises offer single bedroom accommodation for all service users. Communal space provided includes, a lounge, conservatory,kitchen,bathroom and shower room. The service users have access to a large well maintained rear garden. Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission of Social Care Inspection is upon the outcomes for Residents, and upon their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting 2 service users and tracking the care they receive through review of their records, discussions with them, and with the staff, and observations of care practices. The inspection took place during an evening, over a period of 3 hours and was carried out on an unannounced basis. Communal areas, and some bedrooms were visited. A selection of care records, and essential records of the home were reviewed. All of the service users, apart from one person on holiday, were spoken to as part of the inspection process. Two members of staff were on duty during the inspection. The Acting Manager was not available. The Commission had received a number of comment cards from residents, relatives, a Care Manager and a Doctor prior to the inspection. In the main the comments recorded were positive and praised the home and the staff for the way in which the care is provided. What the service does well: The home provides a family style environment, which the residents said they like. The group have lived together for several years and there have been no new admissions recently, although there is presently one vacancy. The residents are involved in the running of the home and staff supervise and assist residents with cooking, and the domestic duties required within the home. Service users choose what activities they wish to participate in, and are able to go on at least two holidays a year. A service user commented that staff assist her to go shopping, which she thoroughly enjoyed. Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 6 The home was decorated to a reasonable standard and the service users bedrooms that were inspected were personalised containing, personal items, and had been decorated in colours chosen by them. The home had a warm relaxed and comfortable feel to it, and staff were observed to be listening and interacting with the service users. 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. Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 5 Prospective service users have the required information to enable them to make an informed choice about the home. EVIDENCE: There has been no new service users admitted for some considerable time, however the Statement of Purpose has been developed and written to provide sufficient information for prospective service users to be able to make an informed judgement about whether the home will be able to meet their needs. The Service User Guide was written in a question and answer format, and was found to be informative and helpful. Contracts, written in a format suitable for the service users had been agreed with, and signed by the user. The contracts reflected the areas stated in the standards. Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 and 10 Although care records require some additional development, the current practices ensure that the health care needs of the people in the home are being met. EVIDENCE: The current care plans contain information about the service users but would benefit from being amplified. The necessary care has been identified but the records do not always contain sufficient instruction and guidance for staff to provide care, in ways chosen by the service user. For example one plan indicated that the service user required assistance in the kitchen but did not specify the kind of help required. There was no evidence that the care plans had been reviewed on a monthly basis as written in the homes policy. (A recommendation has been made) Throughout the inspection it was observed that service users made decisions and staff supported them. One example was that a service user wished to go shopping; this request was supported by a member of staff, who began to make arrangements with the service user for a shopping trip. Service users were keen to show their rooms with colour schemes and furniture chosen by them. Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 10 Individual risk assessments had been carried out, with detailed instructions and guidance for staff of how to manage and minimise identified risks, although there was no evidence that risk assessments had been reviewed on a regular basis. (A recommendation has been made) Records were seen to be kept securely, and discussions with staff indicated that they were aware of their responsibilities regarding confidentiality. Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 and 17 Service users views are sought and acted upon in respect of their daily lives, and they are given opportunities to maintain appropriate and fulfilling lifestyles in and outside of the home. EVIDENCE: Service users are supported in various day centres, according to individual interests and abilities. Service users expressed their enthusiasm for their daytime activities. Service users interviewed said that they were happy with the routine at the home and felt able to follow their own interests when they wished. During the inspection service users were observed to be making choices about how they spent the evening; one preferred to remain in her room, another was watching the television and another sat in the garden. From the information gathered from the Pre-Inspection Questionnaire, records and discussions with service users and staff, there are a range of opportunities for the service users to access community based activities, for example Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 12 shopping trips, sporting activities, social clubs, countryside walks, and swimming. One service user said that she enjoyed visiting horses. Service users are free to entertain family and friends at any reasonable time within the home. Some service users also spend time away from the home with their families at weekends. The service users have three meals a day of which one is a cooked meal, alongside snacks and drinks. Weekly menus are provided, and the meal on the night of the inspection consisted of liver, bacon, mashed potatoes and onions. Service users were very positive about the food provided and staff said that they were encouraged to assist with meal preparation, and clearing up the kitchen according to their individual skills. Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19. The outcome that the service user’s health, personal and social care needs are set out in an individual plan of care was achieved. EVIDENCE: None of the service users require assistance with personal care, but require encouragement and motivation to complete the tasks themselves. There was evidence within the files that other professionals were involved with health care needs. For example the records show that General Practitioner, Chiropodist, Dentist and Optician appointments are arranged on a regular basis. Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The complaint and protection process within this home is adequate and sufficient to protect residents. EVIDENCE: All Relative/visitor comment cards confirmed that relatives are aware of the homes complaints process, but had not had course to use it. The preinspection questionnaire, and the records held by the Commission of Social Care Inspection confirmed that no complaints had been received, since the last inspection. The home has a complaints policy that would benefit from having time limits stated, otherwise was clear and concise and in an appropriate format. A service user said ‘ if I am unhappy I tell the staff’. Staff said that regular meetings are held with service users and ways of assisting them to make their views known are continually explored. Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 The environment provides safe comfortable surroundings and is maintained to an acceptable standard. EVIDENCE: The Home is suitable for its stated purpose and provides service users with appropriate living space. The premises were generally well maintained, comfortable, bright, and cheerful. Standards of domestic and hygiene maintenance were appropriate at the time of inspection. The Home is close to the town centre, and accessible by public transport. It offers a family styled environment to its service users and is in keeping with the local community. The kitchen area was tidy, with work surfaces clean, and all perishable foodstuffs appropriately refrigerated. Kitchen equipment, such as the cooker, refrigerator, and freezer were suitable in capacity for the needs of the service users. Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 16 Two of the service users rooms were seen during this inspection, both rooms were clean, comfortable, appropriately furnished and personalised. A service user confirmed that she had chosen the colours for the room and that she was happy with her room. One service user enjoyed doing jigsaws and had a table in her room large enough to complete a 5000 piece puzzle. A problem identified at a previous inspection concerning the downstairs shower facility was being addressed. Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 The staff team are experienced, knowledgeable about the service user group, and committed to improving the quality of life of the people they care for. EVIDENCE: Staff files were not available at the inspection, however from information gathered from the pre-inspection questionnaire and through discussions with the staff it was evident that there had been a wide variety of training completed, including statutory, and specialised training to meet the needs of the service users.2 members of staff had obtained a National Vocational Training qualification. Staff and service users both stated that staffing levels were adequate. This was further supported from relative’s comments within pre-inspection questionnaires. Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The well being, health and safety of the residents is promoted, and protected through staff observations and actions, policies and procedures EVIDENCE: Since December 2002 Lesley Anita Fagg has been acting manager and has been appointed by MENCAP to manage the home. Ms Fagg has subsequently been seconded to manage another MENCAP home for a period. During this time Deputy Manager Amanda Mc Queenie has been promoted to Acting Manager. Staff confirmed that faulty equipment is replaced or repaired, and observations made during the inspection confirmed that the residents live in a safe environment. Records observed included the fire log- book, which was found to be satisfactory, apart from the testing of the emergency lighting (a requirement has been made). Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 19 Policies and procedures relating to safe practices are available for all staff, and training on health and safety is kept up to date. A member of staff confirmed that there was an adequate supply of disposable gloves and aprons available for staff that may need to assist with personal care. Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x 3 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Queensberry Road Score x 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 42 Regulation 23.4 Requirement The emergency lighting system must be checked on a regular basis Timescale for action 11-07-05 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. Refer to Standard 6 9 Good Practice Recommendations The care plans should be developed to include sufficient instruction and guidence for staff in the provision of care, and be reviewed on a regular basis. Risk assessments should be reviewed on a regular basis Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 1st Floor Newland House Campbell Square Northampton, NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Queensberry Road D C51 C08 S12891 Queensberry Road V232689 300605 stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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