Inspection on 06/01/07 for Queensbridge House

This inspection was carried out on 6th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Queensbridge House 13/02/06

Queensbridge House 08/11/05

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Queensbridge House 63 Queens Road Cheltenham Glos GL50 2NF Lead Inspector Mrs Helen James Key Unannounced Inspection 6th March 2007 09:00 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 Queensbridge House DS0000065411.V316869.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. Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queensbridge House Address 63 Queens Road Cheltenham Glos GL50 2NF 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) 01242 519690 01242 539059 Queensbridge Care Limited Mrs June Linda Stanton Care Home 27 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (27), of places Physical disability over 65 years of age (1) Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Four (4) beds to accommodate service users between the ages of 50 and 65 years. 13th February 2006 Date of last inspection Brief Description of the Service: Queensbridge House is a large detached house, which has been extended and refurbished to provide residential accommodation for twenty-seven elderly residents. It is situated in a residential street close to Cheltenham Railway Station. The Home is on a bus route and is within easy reach of Cheltenham town centre. The accommodation consists of twenty-five single bedrooms, twenty-three of which have en suite facilities, plus one double room. Access is gained to the upper floors with the aid of the shaft lift, stair-lifts or stairs. Comfortable communal rooms are provided throughout the building. The Statement of Purpose and Service User Guide are available in the office. Fees for the home range from £425 to £750 per week. Items not covered by this fee include Chiropody, Hairdressing and magazines/papers and toiletries. The residents have the benefit of an enclosed private garden, which may be enjoyed in Summer months. Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Unannounced inspection took place over nine hours on one day in March 2007. Twenty- nine Care Standards for Older People including all the twenty-two Key standards were assessed on this occasion. Of these six exceeded the standard, twenty met the standard, two almost met the standard and one was not applicable. Time during the inspection was spent speaking with the Manager Mrs Stanton, Director Mrs Saunders, staff, residents and visitors, examining documentation, management records and the environment. Those residents/visitors who were able to converse with the inspector discussed the admission process, care, food, lifestyle, activities and the staff at the home. The information in relation to care and welfare gained from these discussions and observations was then cross-referenced with residents’ individual care records and other appropriate documentation. Questionnaires were sent out prior to the inspection and analysed prior to the site visit. The three responses from residents were all very positive about the care, food, activities and staff. One resident even commenting, “that the staff were very kind and helpful.’ The five responses received from relatives/visitors were again very positive about the management of the home, care, food and attitude of the staff. One relative commented that didn’t know the complaint procedure but all spoken with knew who to contact to complain when they didn’t feel satisfied. The four responses from the staff were very positive about the home, support, training and management encouragement they receive whilst at work. What the service does well: The home has a Manager who is greatly involved in the home on a day-to-day basis and has worked at the home a number of years. There appears to be an open, friendly approach to the running of the home, where resident’s needs are paramount and this is reinforced in the training and example given to staff. This results in Queensbridge being run safely and efficiently with residents’ rights, independence and choice being safeguarded and protected whilst involving them and their families. It was evident through discussion with residents/relatives who were able to talk to the inspector that they felt their views were always taken into account. They found the Manager and staff approachable and friendly. Residents spoken with all confirmed that they are very happy with the home; the care they receive and they had no concerns. They felt they were kept well informed and that there is appropriate stimulation in the home and the ability ‘to do what you like when’, and ‘to do as little or as much as you want’. There was confirmation that residents were given choice in what they do and that Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 6 independence is promoted as much as possible. All the comments made by residents, relatives/representatives in conversation and via questionnaires were very positive about the home, staff, care, activities and the food. Interactions and communication between staff and residents was observed during the inspection and it was noted that tasks were undertaken diligently, respectfully and compassionately. Staff engaged with individuals during all interactions and during these times resident’s dignity, privacy and respect were maintained. The atmosphere in the home was calm and unhurried. Management records relating to health and safety issues and regular checks were in place. There was evidence that if any action had been necessary that it had been completed. All incidents and accidents that require reporting under regulation 37 are completed and sent to the Commission. The Manager and Director have an array of documented auditing tools in place to examine quality and effectiveness of systems in the home, which contribute to the Quality Assurance of the home. What has improved since the last inspection? What they could do better: When the Manager starts staff with a Povafirst check only before the CRB returns, she must ensure that there is evidence of the risk assessment and the working with another carer is on the induction proforma, to evidence the processes put in place by the Manager to safeguard residents. To enhance the Quality systems further an auditing tool for care practice should be developed and ways of seeking and evidencing the views of community stakeholders about the quality of service provided to residents need to be devised. An annual Quality Assurance report must be produced to evidence the review of the effectiveness of the quality systems in the home and this must include stakeholders’ views and future developments for the home. In conclusion Queensbridge House provides excellent standards of care in a comfortable environment for its residents who are of varying abilities. The inspector found a warm, relaxed and welcoming atmosphere that felt homely and comfortable for residents and visitors Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 7 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. Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 8 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 Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4, 5 & 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users and their relatives are well informed about the home prior to admission. Arrangements are in place to ensure that each prospective resident is fully assessed prior to admission. This is reassessed on admission, to ensure that all their specific care needs can be met by the Home. Residents or their relatives have the opportunity to visit the home. Intermediate care is not provided. EVIDENCE: The home has a Statement of Purpose and a Service User’s Guide; this has been reviewed for a variation this past year and a copy has been sent to the Commission. Yearly reviews are carried out to ensure that residents and their families receive accurate information about the home and services provided. Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 10 Residents are assessed prior to admission and they are encouraged to visit the home for a short stay, for tea or lunch or to see the home and meet people before they come in. Residents/relatives spoken with confirmed that there was an assessment by the Manager of the home prior to admission and that they were reassessed once they arrived at the home. They confirmed they were involved in the process with their relatives/representatives and the member of staff, talking to them about their care. Documentary evidence of the assessment process was available to demonstrate this and residents or their representative had signed these. The Manager and staff keep in contact with the family and friends all the time discussing things with them at each visit. There are formal and informal reviews of the placement and contract with family/resident/ staff and all those involved with the individual by the Manager. Residents confirmed that they or their relatives visited the home prior to the admission and found the home to be very suitable. Residents had contracts (a sample were seen) private and social services, but it was not always the resident who was involved with this some left it to their relatives/representative or Social Worker; some did not want the worry of this. The contract contained all the required details and is reported to be compliant with Office of Fair Trading Standards. Relatives/representatives of people recently admitted were spoken with and all confirmed that they are very happy with the home and they had no concerns. They felt they were kept well informed and feel that there is appropriate stimulation in the home and the ability to do what you like when, to go out as you please and to visit whenever you wish. There was confirmation that residents were given choice in what they do whilst independence is maintained as much as is possible. All the comments made by residents, relatives/representatives in conversation and via questionnaires were very positive about the home, staff, care, activities and the food. Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 11 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. The care planning systems ensures that all members of staff have a clear understanding of the care each person requires and how it is to be given. All Health Care needs are fully met. Residents are treated with respect and dignity and end of life wishes are recorded. EVIDENCE: Care records seen included a photo of the resident; an assessment of the residents needs prior to admission or on admission and diagnosis. The assessment was based on general information and on the activities of daily living in order to ascertain that the residents needs could be met A plan of care is then written based on the residents needs in conjunction with the resident, who then agrees to the care by signing the documentation if able too. (Evidence seen). Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 12 Care plans seen had the relevant documentation in and care plans related to the identified needs. Risk assessments were appropriate to individual needs and all had moving and handling assessments recorded. No residents were self-medicating a documented risk assessment would be present if they were. Consent is recorded where necessary and where a resident requests not to have something done then this is recorded and signed by them. Weight is monitored and recorded where necessary but a baseline is always taken on admission. Bathing records were also available. The past lifestyle, activity, hobby interests is recorded and records of attendance at activities are recorded. Care and interactions of staff were observed as sensitive, approachable, respectful they were observed dealing with residents with dignity and privacy and facilitating choice as much as possible where residents were able to voice this. Where they were not able to make a choice due to an inability to communicate this to staff, staff were diligent in their communication, guiding and reassuring residents appropriately and respectfully. Residents have the district nurse for dressings, continence and injections at this time. District Nursing (DN) records are kept in the home. The home is ‘trialling’ some new care records alongside the old ones at this time and these will be reviewed after three months. The inspector found these to be complicated and not easy to understand, as they were graphical in their layout. The inspector felt that these would not adequately capture the information that was necessary and would be difficult for care staff to complete and understand; a small amendment to the way the current ones are completed/used would be sufficient to address the issues that the manager discussed during the inspection. i.e.; separating the intervention and the evaluation/review. Also the identified problem/need and Interventions in care records needs to be written clearly and simply. The Manager and deputy are responsible for the ordering and signing into the home the medication. The system has been reviewed and the home now sees all repeat prescriptions, which once completed are sent to the surgery. The surgery then sends the prescription back to the home where it is checked and sent to the chemist. The medication is then dispensed resulting in fewer errors. When the order is sent to the home it is, logged in and signed on the MAR sheet. The home is moving over to a ‘Nomad- concise’ system that is much lighter to handle and easier to store and manage. The Chemist supplying this system will provide training and education for Medication administration in conjunction with ASSET so the staff will all receive accredited training. The Manager audits the medication when new medication comes into the home on the MAR sheet. A recorded auditing system for medication practice within the home is to be set up. Asset training records were seen for those staff already administrating medication. Queensbridge House DS0000065411.V316869.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 excellent. This judgement has been made using available evidence including a visit to this service. Residents experience a stimulating and varied life at the home with visitors and community links encouraged. There is a full activity programme available to suit all abilities within the home. Residents continue to be able to exercise choice and control over their lives within the individual ability to do so and maintain contact with family and friends. The meals at the home are wholesome and nutritious with choice at each meal. EVIDENCE: The past lifestyle, activity, hobby interests of residents are documented and kept in the care file. There is also a record of all the activities that residents participate in within the home. The activity programme is displayed in the home and can be given to residents who stay in their room. The activity coordinator meets with residents when they start to live at the home and lets them know about the activities available and talks to them about the things they would like to do. She does group and ‘one to one’ sessions with residents. She works Mon, Thurs and Sunday. Care staff take residents out for a walk to shops or in the car, when they can or when a resident wishes. There Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 14 are entertainers who come to the home regularly. Afternoons are quieter and care staff tend to spend time with the residents in the lounge areas doing a group activity or ‘one to one’ in residents own rooms. Staff spoken with confirmed this. The home keeps all the required records (there is a contract with an external catering supplier) and the Director audits the provision and shares this information with the Home Manager. The Manager meets with the Director weekly with regard to all matters within the home. Specialist diets can be provided and where residents are deemed as at risk from malnourishment due to medical conditions and/or are losing weight they are monitored monthly and this is recorded. Appropriate intervention is implemented such as nourishment drinks, extra snacks between meals and added supervision when eating. Fluid intake is also monitored where necessary. One resident is on a low fat diet. The residents do not want a meeting at the present time. But the Manager does go around and see all the residents on a ‘one to one’ basis each week and talks to them about their care, meals and any other matters they wish to raise; matters are dealt with as they are raised. It was recommended that the Manager implements a form of recording this interaction i.e.; a book or file with who was seen, issues discussed and action taken. Etc; this interaction was confirmed by residents spoken with. Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 15 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. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: The home has a complaints procedure that is displayed and all spoken with were aware of. Several residents and a relative spoken with stated that ‘they had no concerns about the care or the home and they always felt confident to discuss concerns with the Manager or staff’. This was also evidenced from the questionnaires received. The Manager keeps a log of complaints/concerns and there was evidence to demonstrate that concerns are acted upon as soon as they are made aware to the Manager. The Manager is to look into ways of collating compliments about the service that is provided at the home. The home has its own policy on abuse and adults at risk they have also received the ‘Alerters’ Guide’. The Manager has not yet attended ‘enhanced adults at risk training’ but as soon as a session is available she will attend. All staff have training on abuse awareness/adult protection on induction and are updated regularly and do this within the NVQ training framework as well. The Manager is also looking for a course for staff that are not doing NVQ so that Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 16 she can update them regularly. Staff spoken with confirmed they had received this and in discussion they knew what they would do if they saw abusive practice or saw anything that bothered them. They also told the inspector that there is an open door policy with the Manager so anything can be discussed at any time. The Manager is aware of the Mental Capacity Act 2007 and will arrange training for all staff in due course. Information about how to access Independent Mental Capacity Advocate Service (IMCA’s) will be made available to people. All new starters undertake training to the induction standards and the induction proforma seen takes a period of three months to complete and includes adult abuse and whistleblowing training. All mandatory training is also arranged for new staff. The home now has its own Manual Handling Trainer who trains all staff. Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 17 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, 25 & 26. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The standard of the environment in this home is good with residents having a pleasant, clean and well-maintained environment to live in. EVIDENCE: The Home is well maintained with an ongoing programme of decoration and replacement of furniture to ensure the environment maintains a homely comfortable ambience for the residents. No odours were present. All the required furnishings are supplied in communal areas and in residents’ rooms if required; many residents had personalised their rooms with their own furniture and pictures making them personal and homely. Gardens to the side of the home are safe, accessible, attractive and well maintained and are used by the residents in the better weather. Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 18 One area of ceiling has a leak by the deputy manager’s office and it has had a temporary repair but until the dry weather comes the repair cannot be done permanently as it is an external roof repair job. No other maintenance issues were found, the dining room has been redecorated and carpeted and the handyman had started to re-decorate the lounge. The radiators are to be replaced this summer during the warmer weather for low surface temperature ones. There is a handyman on site daily. All maintenance issues are recorded in the maintenance book on a daily basis and these are addressed each day and signed off when they are completed to ensure an audit trail. All radiators can be regulated for residents. Windows are restricted but do allow for natural ventilation of the rooms. Water is stored at appropriate temperatures and Legionella testing is completed certificate November 2006 was seen. Monthly testing of hot water outlet thermostatic devices is undertaken and recorded by the handyman records were seen. Cleanliness is of a high standard and no infection control issues were identified. COSHH systems are in place. Care staff undertake catering and minimal laundry duties as part of their daily routine and this does not compromise personal care. The laundry in the basement has good hygienic facilities for the laundering of clothes, which complies with infection control standards. There is a laundry person each day and domestic team that keeps the home clean. Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 19 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. Residents’ needs are met by a competent staff team, who have access to a satisfactory training programmes that ensure staff have the knowledge and skills to care for the diverse needs of people living at the home. EVIDENCE: Staff confirmed that they complete an induction course that involves working through an induction proforma. Copies of this were seen at the time of the visit. The registered manager stated that new staff work supernumerary to the staff team for the first month. Rotas confirm that there are sufficient staff working at the home throughout the day. Twelve of the seventeen care staff have a level 2 or 3 award in Care and several care staff are completing their awards. This exceeds the standard. Inspection information confirms that care staff are allocated kitchen duties each shift and are trained to deal with the heating and serving of the prepared frozen meals supplied by the catering company. The Homes Director audits the catering. There are staff responsible for the laundry and cleaning employed by the home. The registered manager stated that she is appointing staff upon receipt of the Criminal Records Bureau check or in exceptional circumstances after a Povafirst check. Out of the last four members of staff appointed three had Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 20 started work with a Povafirst check (CRB checks were received up to a month after they started). The registered manager is advised to complete a risk assessment to describe the processes she has in place when employing staff with a Povafirst check. Recruitment and selection processes are satisfactory with evidence that at least two written references are being obtained as well as proof of identity, an occupational health check and a full employment history. Where there are gaps in the employment history there was evidence that the registered manager is questioning this during the interview process and making notes of gaps. The registered manager confirmed that people living at the home are not involved in the interviewing of staff but do meet potential new staff when they are shown around. A training matrix is in place that gives information about each member of staff’s training for the year (a copy of this is to be sent to the inspector for this year). Each person has the opportunity to attend in- house and training from external providers. Staff confirmed that their mandatory training is kept up to date. Copies of certificates of attendance are kept on staff files. Training specific to the needs of some people living at the home is provided such as diabetes, Dementia etc and training or courses are arranged/provided relating to the needs of people accommodated at the home. Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 21 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, 34, 35, 36 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Management of the home is good and the Manager provides leadership, guidance and direction to staff on a ‘day to day’ basis. The health, safety and welfare of the people using the service are protected and safeguarded and the home is run in their best interests offering them choice, respecting their wishes and keeping them safe. The systems for service user consultation and quality assurance are developed in the home and could be enhanced further by stakeholder consultation and an annual quality report. EVIDENCE: The manager has NVQ level 4 in Care and Management. She actively pursues her continuing professional development and attends training courses. Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 22 From questionnaires; the staff reported that the Manager is approachable accessible and a good role model working alongside them in the home and has an open door policy so is accessible at all times. They feel they have good support from her and have appraisals with her or the deputy and receive regular supervision. The registered manager described the quality systems she has in place to audit processes, health and safety, accidents, catering, sickness and medication within the home. People take part in an annual quality assurance survey and the Manager was advised to survey external people who use or visit the service and from all of these systems produce a quality assurance report indicating what has been successful and what requires attention and how the home intends to address any issues identified. This should then be available or displayed in the home. The Manager reported that the Director is looking at the home being accredited with the Investors in People Award. The quality of recording for people’s personal monies is good and audited regularly and signatory evidence was seen. The Manager described the processes that are in place. Records for three people were examined. Receipts can be cross-referenced with transactions and auditing is easy. Staff confirmed that they have an annual appraisal and copies of these were seen on files. The manager states that she observes staff practice regularly although there is no evidence of this. Records confirm that staff receive six supervision sessions each year. The record indicates the dates and the variety of things discussed all records were signed. One induction record for a new member of staff could not be found during the inspection. It is recommended that when policies and procedures are reviewed and updated the date of updating be put on the bottom of the page. The radiators throughout the home are to be replaced this summer with low surface temperature radiators; the inspector has agreed to carry this forward from the last report due to the inability to get a plumber to do the job last summer and to lessen the risks to residents as it has to be done during the warmer weather. Health and safety systems are in place and are being monitored and reviewed. Water temperatures are regularly taken for outlets around the home. There are comprehensive records in line with ‘Safer Food Safer Business’ guidelines. First aid and COSHH risk assessments are displayed around the home. The pre-inspection questionnaire and service inspection documents confirm that equipment is regularly serviced. Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 23 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 4 4 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 3 3 3 X 3 Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 24 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 OP25 Regulation 13(4) Requirement All radiators to be protected to prevent accidents. (Carried forward from last report timescale for 2006.) Timescale for action 30/09/07 2. OP18 13(6) 3. OP29 19 schedule 2(6) The Manager to attend 30/05/07 ‘enhanced adults at risk training’. This has been booked for November 2007, the first available date. All new staff must have a current 30/04/07 Criminal Records Bureau check in place before they start work protecting people from possible harm. Risk assessments should be documented for staff starting work on a Povafirst check describing how people are protected from possible harm. This has been put in place before report publication. The Registered person must produce an annual quality assurance report to evidence the review of the quality systems in the home. This must include DS0000065411.V316869.R01.S.doc 4. OP29 19 Schedule 2(6) 30/04/07 4. OP33 24 (2) 30/09/07 Queensbridge House Version 5.2 Page 25 stakeholders’ views and future developments in the home. 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 OP7 OP9 OP14 OP38 Good Practice Recommendations The identified problem/need and Interventions in care records needs to be written clearly and simply. Devise a recorded auditing system for medication practice within the home. Manager to implement a form of recording the weekly ‘one to one’ meetings with residents. When Policies and Procedures are reviewed and updated the date of updating must be put on the bottom of the page. Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Queensbridge House DS0000065411.V316869.R01.S.doc Version 5.2 Page 27 - 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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