Inspection on 05/10/05 for Queensway

This inspection was carried out on 5th October 2005.

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 no outstanding requirements from the previous inspection report, but made 10 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 28/02/06

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 5th October 2005 1.30pm Queensway DS0000001125.V258202.R01.S.doc Version 5.0 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.V258202.R01.S.doc Version 5.0 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.V258202.R01.S.doc Version 5.0 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.V258202.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th March 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.V258202.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place between 1.30pm and 5.10pm. One inspector conducted this inspection visit. The inspector had the opportunity to meet three service users during the course of the inspection. Limited time was spent with the service users as most were out during the inspection. The inspector had lengthy discussion with the registered manager, examined records, and accessed all areas of the home. What the service does well: What has improved since the last inspection? What they could do better: Some elements of individual care plans and risk assessments need to be more detailed so that care staff are clear about how to meet service users’ needs and protect them from harm. Queensway DS0000001125.V258202.R01.S.doc Version 5.0 Page 6 Clear guidelines need to be developed to inform staff how to manage service users’ behaviours using ways that are recognised as current good practice. 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. Clear written guidance must be produced for staff as to when to give “as required” medications. The complaints procedure needs to be made available to service users and their families. The home needs to publish the results of service user satisfaction surveys. 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.V258202.R01.S.doc Version 5.0 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.V258202.R01.S.doc Version 5.0 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): EVIDENCE: None of the above standards were assessed on this occasion. Queensway DS0000001125.V258202.R01.S.doc Version 5.0 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): 6,9 Some parts of service users’ care plans were clear and detailed, however some parts of service users’ care plans need to be more detailed so that staff have clear guidance about how to meet individuals’ needs. Some service users’ risk assessments need to be more detailed. EVIDENCE: Two individual service user plans were examined as part of this inspection. The quality of information within the plans was mixed. Some areas were detailed and gave clear guidance to staff about how to support service users, however some parts of the plans were unclear and did not contain sufficient information. Further information is required to ensure that all aspects of service users’ personal, social and healthcare needs are covered. The plans must also include any restrictions on choice and freedom that have been agreed with the service user or their advocate. There must be a clear rationale and risk assessment in place in respect of any restrictions. For example, soap and towels not provided in bathrooms and toilets, food locked away. Individualised procedures for service users likely to be aggressive or cause harm or self-harm need to be included. These should focus on positive behaviour, ability and willingness. The inspector saw an example of a clear Queensway DS0000001125.V258202.R01.S.doc Version 5.0 Page 10 management plan regarding a specific behaviour. This was unambiguous and focused on de-escalation and reinforcing positive behaviours. It was suggested to the manager that this be used as guidance when developing further behaviour management plans. The use of prn medication to manage behaviours should be included within the plan. See standard 20 for further information in respect of medication. There was evidence in the records sampled that not all parts of agreed care plans were implemented, for example, weekly weighing had not occurred as agreed within an individual’s care plan. Some daily records were vague and did not demonstrate that service users’ needs had been met as per the individual care plan; for example, one service user’s records regularly stated that they had been ‘settled’. As with the care plans, some of the risk assessments need to be developed further to ensure they are clear and unambiguous. For example, a risk assessment suggested that ‘time out’ be used with a service user. The manager said that ‘time out’ wasn’t used; the risk assessment must be reflective of the practice. Risk assessments in respect of restrictions placed upon service users must be developed, eg, towels and soap not available to service users in the bathrooms and toilet, food locked away. Queensway DS0000001125.V258202.R01.S.doc Version 5.0 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): 13,14,15,17 Service users are offered opportunities to access community facilities on a regular basis. Service users enjoy a variety of leisure activities. Service users receive good support to enable them to maintain links with their families. Service users are offered a healthy diet. EVIDENCE: There was evidence in records that there are regular opportunities for service users to access a range of community activities. On the day of inspection, a group of service users were supported to go out on a trip with staff. A variety of leisure activities are available to service users in the home including TV, DVD player, stereo, multi sensory equipment and games. There was evidence in records that service users are supported to maintain family links and friendships. The manager described how staff have supported Queensway DS0000001125.V258202.R01.S.doc Version 5.0 Page 12 a service user to re-establish links with a family member. All service users have contact with family, befriender, advocate or friends outside of the home. The menus were examined and found to offer a varied and reasonably balanced diet. Fruit and vegetables must be included on the menu; the manager stated that these are offered on a daily basis and there was fresh fruit and vegetables in the home. The manager said that service users are supported to participate in food preparation, setting the tables and clearing up after meals. Queensway DS0000001125.V258202.R01.S.doc Version 5.0 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. The registered person needs to improve the information and guidance given to staff about when to administer prn medication to service users. EVIDENCE: Additional information needs to be included within individual care plans about how service users prefer to be supported with their personal care. Not all records examined clearly set out service users’ preferred routines, likes or dislikes. This is particularly important for service users who cannot easily communicate their needs. 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. Service users were not always supported to maintain their privacy and dignity during the inspection; Queensway DS0000001125.V258202.R01.S.doc Version 5.0 Page 14 some service users require support to close bathroom/toilet doors whilst they are in use. Service users’ records showed that service users are supported to access healthcare services on a regular basis. It was noted that monitoring of healthcare as recorded in the care plan is not always implemented as intended. This was discussed with the manager at the time of inspection. An OK health assessment is conducted with all service users by nursing staff in the home. Medication was not assessed at this inspection with the exception of the prn, as required, medication for one service user. Records relating to the administration of this medication did not demonstrate that the guidelines had been followed. The guidelines need to be more detailed and specific, for example, rather than stating that medication should be given if the service user is agitated, there must be clear guidance about what behaviours would be classed as agitation. These should be included as part of a general behaviour management plan. Queensway DS0000001125.V258202.R01.S.doc Version 5.0 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): 22 The home has a complaints procedure in place. This must be made available to service users and their relatives/advocates. 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. The manager was unable to locate the version of the procedure that would be given to service users or their relatives/advocates in the event that they wanted to make a complaint. This must be made available. The correct name and address of the CSCI have now been included in the procedure as required at the last inspection. Queensway DS0000001125.V258202.R01.S.doc Version 5.0 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): 24,30 Service users live in a clean, comfortable home that has plenty of space. Each service user has their own bedroom. EVIDENCE: The inspector had the opportunity to look around all bedrooms and the communal areas of the home. The home is in a good state of repair and is domestic in style; it is comfortable and is furnished to a good standard. Each service user has a bedroom that is single occupancy and these were personalised to reflect service users’ interests and hobbies. The house has a lounge and separate dining room. There is an office and a separate staff sleep in room. It was noted that soap and towels are not provided in the bathrooms or toilets. The manager explained that this is due to some service users’ behaviours. Any such restrictions must be agreed, recorded and risk assessed and must be subject to regular review to ensure that restrictions are reduced or removed at the earliest opportunity. The manager reported that service users are supported to wash their hands in the hand-washing sink in the kitchen. Queensway DS0000001125.V258202.R01.S.doc Version 5.0 Page 17 The home was clean and free from unpleasant odours at the time of inspection. Policies and procedures in respect of infection control are in place and satisfactory arrangements have been made for the disposal of clinical waste. Queensway DS0000001125.V258202.R01.S.doc Version 5.0 Page 18 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): 32,33,35 Staff working at the home have relevant qualifications and experience. Relevant training is provided to staff. EVIDENCE: Of six care staff working at the home, 2 are qualified to NVQ level two or above and one is working towards level three. The home is on line to achieve the recommended 50 of care staff qualified to level two or above by the end of 2005. The manager reported that one of the care staff is currently completing the Learning Disability Award Framework induction and foundation training and will start NVQ training following this. Two of the care staff are due to retire in the next two years and have therefore requested that they don’t complete the NVQ training. There is a comprehensive training and development plan in place and staff regularly attend relevant training. All new care staff complete the Learning Disability Award Framework induction and foundation training. Some service user records that were examined suggested that staff were not always responding to service users’ behaviour appropriately. This was discussed with the manager at the time of inspection who said that he believed that staff were not always recording accurately rather than responding inappropriately. This must be explored further by the manager and further training arranged as Queensway DS0000001125.V258202.R01.S.doc Version 5.0 Page 19 necessary. The inspector did not have the opportunity to talk to staff during this inspection as they were supporting service users out on an activity. There are seven qualified nurses employed at the home, three of which are part time and one is currently on maternity leave. There is a qualified nurse on duty at all times with either one or two care staff. The manager explained that St Anne’s are currently recruiting to a twenty-five hour vacancy for a driver and when this position is filled the home will be fully staffed. This will increase the opportunities that service users have to participate in communitybased activities. Queensway DS0000001125.V258202.R01.S.doc Version 5.0 Page 20 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): 39,42 Satisfactory quality assurance and monitoring systems are in place at this home although a system for publishing the results needs to be developed. The home is maintained in line with safe working practices. Improvements in service users’ individual plans must be made to include agreed strategies for managing challenging behaviour. EVIDENCE: The home has an annual development plan in place. The provider sends out satisfaction surveys to service users and their families/advocates. There was no evidence that the results of these surveys are published or made available to the service users or their representatives; it would be good practice that this be arranged. Records regarding health and safety matters were in good order. There was evidence in the records that the required checks and maintenance of safety equipment is carried out. The fire alarm is tested weekly as required. Queensway DS0000001125.V258202.R01.S.doc Version 5.0 Page 21 Development of clear strategies is necessary to enable staff to safely and effectively manage potential incidents of challenging behaviour; this should be completed as part of the service users’ care plans and risk assessments. Queensway DS0000001125.V258202.R01.S.doc Version 5.0 Page 22 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 X X X X X Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 X X 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 3 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Queensway Score 1 1 1 x Standard No 37 38 39 40 41 42 43 Score X X 1 X X 1 x DS0000001125.V258202.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? No – one not assessed and has therefore been carried over. 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 YA34 Regulation 19(b) Requirement Timescale for action 31/05/05 2 YA6 YA18YA42 3 YA9 YA42 4 YA19 YA42 Staff details must be kept within the care home and contain the information as required on Schedule 2. Not assessed on this occasion. 12(1)a,15(1), An up to date, comprehensive, 07/12/05 Sch 3 person centred plan must be in place for all service users. This must include personal support needs, behaviour management plan including physical intervention plan, a record of any limitations agreed with the service user as to the service user’s freedom of choice, liberty of movement and power to make decisions. 13(4) Detailed risk assessments 07/12/05 must be in place for all service users that empowers individuals to participate in as many daily tasks and activities as possible. Risk assessments currently in place must be reviewed. 12(1)a The registered person must 30/11/05 ensure that where it has been agreed that a service user’s weight is monitored weekly, DS0000001125.V258202.R01.S.doc Version 5.0 Queensway Page 24 5 YA20 12(1)a,b 13(2) 6 YA39 24(2) this is implemented as intended. The registered person must ensure that prn medication guidelines give clear instructions about when medication should be administered. Prn medication must be administered as per the instructions and guidance. The registered person must make the results of service user/relatives surveys, in respect of quality of care provided, available to service users. 30/11/05 31/12/05 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 YA17 YA22 Good Practice Recommendations Menus should include fruit and vegetables. The complaints procedure should be made available to service users or their families/advocates. Queensway DS0000001125.V258202.R01.S.doc Version 5.0 Page 25 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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