Inspection on 17/10/06 for Queensway

This inspection was carried out on 17th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Queensway 27/11/08

Queensway 04/07/07

Queensway 28/02/06

Queensway 05/10/05

Queensway 08/03/05

Queensway 29/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Grayling

The Cornerstone

John Street Nursing Home

Pennine Camphill

Snydale Care Home

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

CARE HOME ADULTS 18-65 Queensway 46 Queensway Kirkburton Huddersfield West Yorkshire HD8 0SR Lead Inspector Karen Summers Key Unannounced Inspection 17th October 2006 08:40 Queensway DS0000001125.V301960.R01.S.doc Version 5.2 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 Queensway DS0000001125.V301960.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 Adults 18-65. 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. Queensway DS0000001125.V301960.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queensway Address 46 Queensway Kirkburton Huddersfield West Yorkshire HD8 0SR 01484 602523 01484 428967 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) jenkinlodge@st-annes.org.uk St Anne`s Community Services Mr Michael Stocks Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Queensway DS0000001125.V301960.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: Queensway is situated in a residential area of Kirkburton and offers nursing care for up to six service users with learning disabilities. The accommodation is on two floors, five bedrooms on the first floor and one bedroom on the ground floor. Rooms are single occupancy and do not have en-suite facilities. There is a bathroom and toilet on both the ground floor and first floor. Communal areas are of a domestic nature and furnished to a good standard. The home has its own transport that service users contribute towards. Fees at the home start at £437.68 - £449.67 per week. Items not covered by fees include holidays and toiletries. Queensway DS0000001125.V301960.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to a key inspection which included an unannounced site visit on 17 October 2006 and the duration of the inspection was 6 hours. There were 6 service users in residence on the day. Mr Michael Stocks, manager, was present throughout the inspection. The following areas were looked at and have been used in the production of this report: a sample of records, care plans, medication, individual discussion with service users, two members of staff, tour of the premises and document reading. To reflect the views of those who use the service, satisfaction questionnaires were sent to 6 service users, none were returned; 6 relatives/advocate/ friends; 4 were returned, and GPs;1 was returned. The inspector would like to thank those who contributed to the inspection process, and also thank Mr Stocks, his staff and service users, for their time and hospitality on the day of inspection. What the service does well: What has improved since the last inspection? What they could do better: The home should continue to audit the medication on a regular basis, and staff should use both their forename and surname initials when signing the drug administration charts. Queensway DS0000001125.V301960.R01.S.doc Version 5.2 Page 6 The worn lounge carpet should be replaced. 50 of care staff should have an NVQ 2 or equivalent. Care staff should receive formal documented supervision at least six times a year. All staff must receive up to date fire training. Staff are recommended to have two fire drills and lectures a year. All staff must have up to date movement and handling training. 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. Queensway DS0000001125.V301960.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Queensway DS0000001125.V301960.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2-5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No service user moves into the home without having had his/her needs assessed and been assured that those needs will be met. Prospective service users have an opportunity to visit and assess the quality, facilities and suitability of the home. Each service user has a service user agreement/contract of terms and conditions with the home. EVIDENCE: The home has not had a new admission since 1990 however, Mr Mick Stocks, the manager, said that he would visit the service user in their place of residence. He also said that he would carry out a pre admission assessment, and the prospective service user would be invited to tea and then an overnight stay before making any decisions to live there. Once the manager was satisfied that they could meet the service user’s needs, then they would be offered a place at the home. A service user agreement is kept for each resident and includes the fees for living at the home. Queensway DS0000001125.V301960.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal and social care needs are set out in an individual plan. They make decisions about their lives, with assistance as needed, and are supported to take risks as part of an independent lifestyle. EVIDENCE: The care records were of a good standard and included risk assessments, goals/needs, and the likes and dislikes of the service user, and there was evidence to suggest that the documents had been reviewed and updated. The records included information to support the wishes of service users, and how they had been assisted to make decisions. A questionnaire received from a relative stated that their relative “is extremely well cared for, with genuine affection and long standing knowledge of his needs and his habits.” “I am extremely satisfied.” “Queensway is a real home in the true sense of the word.” Queensway DS0000001125.V301960.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users take part in appropriate activities and are part of the local community. Service users are encouraged to maintain contact with their family and friends. Service users receive a varied diet that takes into account their likes/dislikes and dietary needs. EVIDENCE: Leisure, holidays and special occasions and likes and dislikes are written in detail in the service user’s “Person Centred Plan.” Service users are also encouraged and supported to develop and maintain independent living skills and participate in a wide range of social and recreational activities, and each service user has a weekly activities timetable. Activities include swimming, horse riding, aromatherapy, Snoezelan (relaxation therapy), college etc. All Queensway DS0000001125.V301960.R01.S.doc Version 5.2 Page 11 service users go on a holiday and their time away from the home depends upon their assessed needs and the individual preferences. Without exception, the relatives’ questionnaires stated that they were satisfied with the overall care provided at the home and contact between relatives and the service users is maintained and encouraged wherever possible. Service users were relaxed and looked well cared for and there was cheerful banter between service users and staff. The menu was varied and took into consideration the likes and dislikes of service users. Queensway DS0000001125.V301960.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional needs are met. Service users are protected by the home’s policies and procedures for dealing with medicines, and medication housekeeping was generally of a good standard. EVIDENCE: Please also refer to standard 6 regarding care records. The care records were a good standard and included the personal support that the service user receives, and there was evidence to suggest that the documents had been reviewed and updated as the needs of the service user changed. Annual health checks are also recorded. In relation to medication, weekly audits are carried out. Qualified nursing staff administer medication and records are kept of all medicines received, administered and leaving the home. One of the audits carried out by the inspector were incorrect, in relation to the amount of medication recorded on Queensway DS0000001125.V301960.R01.S.doc Version 5.2 Page 13 the drug chart and that what should have been left in the container. Audits of the medication should continue so that discrepancies if they arise can easily be identified and resolved. When signing the drug administration chart a number of staff were only using the initial of their first name. Staff should use the initials of both their forename and surname. Queensway DS0000001125.V301960.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 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 can be confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: No complaints have been received at this home since the last inspection. St Anne’s Community Services have a “Tell us what you think” leaflet that includes compliments, complaints and suggestions, and the information also includes photographs and timescales for dealing with a complaint. Robust protection procedures, including whistle blowing, are in place. St Anne’s provides training in the protection of vulnerable adults. There is a whistle blowing procedure and staff have abuse awareness training. Queensway DS0000001125.V301960.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is in a good state of repair and decorative condition and service users’ individual needs are met in a comfortable and homely setting. The premises are clean and systems are in place to control the spread of infection. EVIDENCE: Service users’ rooms were individualised to reflect their tastes and personalities. Generally the home is in a good state of repair and decorative condition. The lounge carpet was thinning in parts and coming away from the skirting board and it should be replaced. The premises were clean and systems are in place to control the spread of infection. Queensway DS0000001125.V301960.R01.S.doc Version 5.2 Page 16 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing levels and skill mix were sufficient to meet the number and needs of service users. Service users are supported and protected by the home’s recruitment practices. EVIDENCE: There is a nurse on duty 24 hours a day and there was a sufficient number and skill mix of staff on duty to care for the number of service users in the home. A questionnaire received from a relative said that, in their opinion, there were not always sufficient numbers of staff on duty. Staff recruitment records are stored centrally and the Provider Relationship Manager from CSCI examines these. There are plans for the future for the evidence to confirm that staff have had the correct recruitment checks to be held at the home. Queensway DS0000001125.V301960.R01.S.doc Version 5.2 Page 17 Forty percent of care staff have an NVQ 2, and further staff are taking the qualification. Due to staff shortages and sickness, not all staff have had recorded supervision on a regular basis. The vacancies have now been filled and staff should have at least six recorded supervisions a year. Queensway DS0000001125.V301960.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are safeguarded by the accounting and financial procedures of the home. The home is run in the best interests of service users. Without up to date movement and handling training, service users’ and staff health and safety is potentially not protected. EVIDENCE: Mr Stocks, the registered manager, is of good character and competent to manage the home. He is a first level learning disabilities nurse and holds a certificate in management studies. Queensway DS0000001125.V301960.R01.S.doc Version 5.2 Page 19 In relation to quality assurance, the Group Manager visits monthly and provides a written report on the conduct of the home and, in addition to this, St Anne’s Community Services has attained the Investors in People award. Fire alarms and emergency lighting are tested/checked weekly and records are kept. The date of the last fire lectures was February and March 2006. All staff must have up to date fire drills and lectures. Staff should have a minimum of two fire lectures a year. Mr Stocks said that none of the service users currently need assistance with movement and handling. Records showed that a number of staff had not had movement and handling up-dates for a number of years. All staff must have up to date movement and handling training in order to understand when needs change and to be able to intervene safely should this happen. Queensway DS0000001125.V301960.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 1 X Queensway DS0000001125.V301960.R01.S.doc Version 5.2 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 YA42 Regulation 23.-(4) (d)(e) Requirement Persons working at the care home must receive suitable training in fire prevention; and take part in fire drills and practices at suitable intervals. You are requested to confirm in writing by 24/11/06 the action you have taken. The registered person shall make suitable arrangements to provide a safe system for moving and handling service users. All staff to have up to date training. You are requested to confirm in writing by 24/11/06 the action you have taken. Timescale for action 24/11/06 2. YA42 13.- (5) 24/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Queensway DS0000001125.V301960.R01.S.doc Version 5.2 Page 22 1. YA20 • The home should continue to keep running totals of medicines administered and regular audits of the medication. Staff should use both their forename and surname initials when signing the drug administration charts. • 2. 3. 4. 5. 6. YA24 YA35 YA36 YA42 YA42 The worn lounge carpet should be replaced. 50 of care staff should have an NVQ 2 or equivalent. Care staff should receive formal documented supervision at least six times a year. All staff should have two fire lectures and drills a year. All staff should have up to date movement and handling training. Queensway DS0000001125.V301960.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 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 Queensway DS0000001125.V301960.R01.S.doc Version 5.2 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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