Inspection on 28/02/06 for Queensway

This inspection was carried out on 28th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 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 17/10/06

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 Alison McCabe Unannounced Inspection 28th February 2006 2:00pm Queensway DS0000001125.V271256.R01.S.doc Version 5.1 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.V271256.R01.S.doc Version 5.1 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.V271256.R01.S.doc Version 5.1 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) 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.V271256.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2005 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 which service users contribute to. Queensway DS0000001125.V271256.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 2pm and 6.45pm and was conducted by one inspector. Service user records were examined and discussion with staff and a service user took place. A number of service users at this home were unable to give feedback about their experiences due to their learning disabilities. The inspector therefore spent time observing practice at the home. Feedback from the service user spoken to was positive. The service user said that she liked living at Queensway and that she got on well with the staff. Most of the requirements and recommendations made at the last inspection had been addressed and this is positive. The registered manager was not on duty at the time of inspection, therefore the nurse in charge assisted with the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Further opportunities to participate in valued and fulfilling activities both in and outside of the home should be offered to service users. Queensway DS0000001125.V271256.R01.S.doc Version 5.1 Page 6 More information about how service users prefer to be supported with their personal care should be included within individual care plans. Any restrictions placed upon service users must be agreed and recorded. Health care plans need to be implemented as intended and a record kept of this. Medication records need to improve. 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. Queensway DS0000001125.V271256.R01.S.doc Version 5.1 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.V271256.R01.S.doc Version 5.1 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 the following standard(s): 2 Appropriate assessments are completed prior to service users being admitted to the home. EVIDENCE: No new service users have moved into this home since 1990. A satisfactory admissions procedure is in place and there was evidence in service user records that a pre-admission assessment had been completed before service users moved into the home. Queensway DS0000001125.V271256.R01.S.doc Version 5.1 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 the following standard(s): 6,7,9 Clear individual care plans and risk assessments are in place. Service users are supported to make some choices. EVIDENCE: Individual care plans for two service users were examined as part of this inspection. Both were found to contain clear information about service users’ assessed needs, although further information is required in relation to how service users prefer to be supported with their personal care routines. It was noted that records of a service user’s weight had not been maintained as agreed within the individual plan. The records showed that there were concerns about the service user’s weight loss. The nurse in charge said that she thought the service user had been weighed regularly but that the records had not been kept up to date. A requirement has been made in respect of this. Each service user has a named nurse and a keyworker who are responsible for ensuring that the individual plan is reviewed regularly. There was evidence in Queensway DS0000001125.V271256.R01.S.doc Version 5.1 Page 10 the records that service users are involved in person centred planning meetings. Service users were observed to choose to spend time alone or in the company of others. The inspector was told that staff choose the menus, however if service users do not like what is on offer, an alternative is offered. Restrictions placed upon service users for safety reasons need to be recorded as part of a risk assessment and kept under review. Some service user risk assessments had been reviewed since the last inspection and all those examined were found to give clear guidance to staff about how to minimize identified risks. Clear behaviour management plans were in place where necessary. Queensway DS0000001125.V271256.R01.S.doc Version 5.1 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 the following standard(s): 12,13,16,17 Most service users are supported to access the community regularly although a full staff team would improve opportunities for all service users. Service users are offered a healthy diet. EVIDENCE: Of the six service users living at Queensway, two attend regular day services away from the home. The staff at Queensway are responsible for the occupation of the remaining service users. The level of required staff support and the current staff shortages are reported to have impacted on the opportunities service users have to access the community. This is reported to impact particularly on the two service users who require two staff to support them when they go out. These service users are the least likely to go out. On the day of inspection, a service user had not been able to attend college due to staffing difficulties at the home. The nurse in charge reported that this was rare. Records showed that service users have attended horse riding, swimming and sensory room recently. The manager explained that, when a driver/carer is recruited, opportunities to go out would increase. The evening of the inspection, staff and service users were in the lounge with the television Queensway DS0000001125.V271256.R01.S.doc Version 5.1 Page 12 on, although most of the service users did not appear to be watching. The inspector saw little evidence of service users being engaged in valued or fulfilling activities. Staff reported that plans for the evening were personal care routines. Service users have access to all parts of their home except the office, laundry and food stores. Service users were observed to choose when to spend time in the company of others or alone. The inspector observed very little social interaction between staff and service users other than support being given with personal care. Menus demonstrate that a balanced and varied diet is offered to service users. Since the last inspection, staff have made efforts to include fruit and vegetables on the menus. The nurse in charge explained that, in addition to the menu (which is a record of what service users have eaten), records of nutrition would also be made in the nursing notes if there were any concerns or if service users had specialist dietary requirements. Evidence of this was seen in the records. A service user told the inspector that she liked the food that was offered. Queensway DS0000001125.V271256.R01.S.doc Version 5.1 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 the following standard(s): 18,19,20 Service users do not always receive personal support in the way they require. Service users are supported to access relevant healthcare services. Records do not always demonstrate that health care plans are implemented as they should be. Medication records need to improve. EVIDENCE: Service users at Queensway need varied levels of support with personal care. It was unclear in the individual service user plans how individuals prefer to be helped in this area. The nurse in charge reported that staff had their own ways of supporting people. In order to ensure consistency and continuity for service users, personal support plans detailing preferred ways of being supported need to be developed, particularly for those service users who are unable to easily communicate their needs. This is particularly important as agency staff are used frequently at the home. Staff reported that times for getting up, going to bed, meal times etc are flexible depending on what arrangements service users have. Some staff were discreet and sensitive when offering personal support to service users whilst some staff were not. Service users looked well cared for in their appearance. Queensway DS0000001125.V271256.R01.S.doc Version 5.1 Page 14 Service users are dependent upon staff members supporting them in hand washing, as there are no towels or soap in the bathrooms and toilet. It was observed that this support was not always offered as staff were not always around when service users required help in this area. During feedback to the manager following the inspection, he reported that paper towel dispensers had been ordered and these would be fitted in the near future. Service users were not always supported to maintain their privacy and dignity during the inspection; some service users require support to close bathroom/toilet doors whilst they are in use. Records that were sampled contained evidence that service users’ healthcare needs are met. Health action plans are in place and an ‘OK health check’ is completed annually. Records showed that service users are supported to attend routine health screening appointments and that specialist health professionals are accessed where necessary. As discussed under standard six, weekly weight monitoring for a service user had not been recorded; this was part of an identified health monitoring plan. Medication records and storage were examined. Since the last inspection ‘as required’ (prn) guidelines for a service user had been further developed and were much clearer than at the last inspection. Whilst most of the medication records were correct, there were a number of errors in recording. A weekly check of the medication is conducted which is good practice. It was found that, on several occasions, medicines held did not tally with the records kept; a number of omissions on the medication administration records were seen. The nurse in charge reported that the increase in number of errors had coincided with the increased use of agency staff, however because the medication was only checked weekly it was impossible to identify when the errors had been made. It is a requirement of the inspection that accurate medication records be kept. Queensway DS0000001125.V271256.R01.S.doc Version 5.1 Page 15 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 the following standard(s): Satisfactory complaints and protection procedures are in place. EVIDENCE: No complaints have been received at this home since the last inspection. St Anne’s has a satisfactory complaints procedure that includes timescales for dealing with a complaint. This was available in the home. Robust protection procedures, including whistle blowing, are in place. St Anne’s provides training in the protection of vulnerable adults. Queensway DS0000001125.V271256.R01.S.doc Version 5.1 Page 16 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 the following standard(s): EVIDENCE: None of the above standards were assessed on this occasion. Queensway DS0000001125.V271256.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 Service users are protected by the home’s recruitment practice and procedures. EVIDENCE: Staff recruitment records are to be checked centrally by the Provider Relationship Manager from CSCI. The home holds a checklist confirming that all the required information has been received prior to staff starting work at the home. The nurse in charge explained that, due to the learning disability of the service users, only one of the people living at Queensway could participate in the recruitment process. It was reported that this has not yet taken place although staff have discussed this. New staff are invited to come to the home prior to interview to meet the service users. Queensway DS0000001125.V271256.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 A qualified, experienced manager runs the home. EVIDENCE: The registered manager is a first level learning disabilities nurse and holds a certificate in management studies. The manager has many years of management experience and working with adults with learning disabilities. Queensway DS0000001125.V271256.R01.S.doc Version 5.1 Page 19 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 X 4 X 5 X 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 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 2 1 X 3 X X X X X X Queensway DS0000001125.V271256.R01.S.doc Version 5.1 Page 20 Yes 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 YA18YA6 Regulation Requirement Timescale for action 30/04/06 2. YA9 3. YA42YA19 4. YA20 12(1)a,15(1), Individual care plans must Sch 3 include personal support needs. Timescale of 07/12/05 unmet. 17(1)(a) A record must be kept of any Schedule limitation agreed with the 3(3)(q) service user as to the service users freedom of choice, liberty of movement and power to make decisions. 12(1)a The registered person must ensure that where it has been agreed that a service user’s weight is monitored weekly, this is implemented as intended. Timescale of 30/11/05 unmet. 13(2) The registered person must ensure that accurate medication records are kept. 30/04/06 10/04/06 10/04/06 Queensway DS0000001125.V271256.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA12 Good Practice Recommendations Service users should be supported to participate in valued and fulfilling activities both in and outside of the home. Queensway DS0000001125.V271256.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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. 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