Inspection on 10/08/05 for Queensway House

This inspection was carried out on 10th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Queensway House 04/06/08

Queensway House 26/09/06

Queensway House 28/02/06

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

CARE HOMES FOR OLDER PEOPLE Queensway House Weston Road Stafford ST16 3UQ Lead Inspector Joanna Wooller Announced 10 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Queensway House Address Weston Road Stafford ST16 3UQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01332 296200 Methodist Homes for the Aged CRH 22 Category(ies) of MD - 22 registration, with number of places Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 11th March 2005 Brief Description of the Service: Queensway House is purpose built unit designed to support 22 individuals with enduring mental health needs. The home is owned by MHA, Methodist Homes for the Aged. The home is split on two floors, a ground floor and a lower ground floor. The premises are located on the outskirts of Stafford, close to amenities and on a frequent bus route. The service users have the enjoyment of patio areas, a green house and gardens around the home. Each service user has an individual flat with a lounge, bedroom, en-suite and kitchen area. Television and telephone sockets were available to those who wished to have their own. There are five flats with the lounge area converted into another bedroom, for those who wish to share. There are adequate communal and activity areas within the home. This home is linked by a corridor to an adjacent home, and has shared catering and laundry facilities.The home operates within a rehabilitationorientated environment. Individuals are actively encouraged to contribute and help formulate their own support plans to achieve realistic goals. Registered Mental Nurses, and teams of resident support workers trained to NVQ Level 2 and above, work alongside the service users to help them achieve their maximum potential. All residents have access to NHS services, professionals and facilities. The home is served by local GP’s, community nurses and a pharmacist. Consultant psychiatrists and psychologists undertake domiciliary visits on a regular basis. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced visit was made on the 10th August 2005 @ 09.30hrs. The inspection was undertaken using the National Minimum Standards for Older People as a reference. The total time spent for the inspection, including pre and fieldwork, amounted to 6hrs. The assistant manager was in charge of the house supported by the Manager. There were 21 service users in the house at the time of the visit. The inspection included the following elements; a tour of the building, observation and inspection of records relating to provision of care, discussions with several service users, discussions with staff members on duty, and inspection of the managerial aspects such as staffing issues, quality assurance and health & safety. Since the last inspection on 11th March 2005, no complaints had been received and no additional visits had been necessitated. A very homely atmosphere had been created throughout the house, and the premises were clean and tidy. Service users were encouraged to keep their own flats/rooms tidy and be as independent as possible. One service user took the inspector to see her flat and was very proud of her efforts to keep it tidy and in order. It was evident that general aspects of care had been well addressed, service user plans had been well written, and some were based on the community care plans completed by social workers. Health, personal and social care needs had been met and well documented. Privacy, dignity and choice aspects for service users were being upheld. No complaints, incidents or reports of abuse of any kind had been received since the last inspection, and policies and procedures seen covered these issues. The home was found fit for purpose and provided a safe environment for the service users and staff. Adequate areas for service users were provided including; communal space, dining/activity space, bathing/toilet facilities, and bedrooms. Services and facilities, including catering and laundry, were adequately provided in Weston House. Health and safety aspects had been given and no shortfalls were noted. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 3 Individual health, personal and social cares needs had been established and were being met by staff, which individually and collectively had the necessary skills and experience. EVIDENCE: The Statement of Purpose was identified as one area that is to be developed in relation to the transition with the new company, MHA. A template has been received in the home, which is to be personalised. Along with other policies and procedures the systems will need to be introduced in to the home with guidance from the MHA managers. The documentation seen by the inspector on the day of the visit evidenced that service users had been assessed prior to admission and they had been enabled to make a choice about the home. All involved had the opportunity to visit the home prior to choosing to stay. The community care plans provided by the social worker were also used, as part of the individual needs assessment process. The service users have nearly all been in the home for many years. The records of the most recent admission was evidenced and found to be satisfactory. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 9 The records seen and a discussion with the staff evidenced that care staff, individually and collectively, had the necessary experience and skills to meet the assessed needs of the current service users. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The individual assessed health and personal care needs of service users had been well documented and were being met, with good standards of care being delivered. There was a safe system for the receipt, storage, administration and disposal of medicines. Service users were treated with respect and privacy and dignity were considered. EVIDENCE: The service user plans and associated documentation was well written, meaningful and reflected the current condition of service users. The documentation seen and a discussion with staff members evidenced that health and personal care needs were being met. NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. Local GP practice and a local pharmacist service the home, and there is a good working relationship with them. Records of their visits and outcomes were seen documented. It was observed that a safe system was in place, and that the comprehensive medicines policy documentation seen was being complied with. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 11 During the inspection it was observed that privacy and dignity were being afforded to residents, and there was very good interaction with staff. Care staff were seen knocking on doors before entering. The service users spoken to were clean, tidy and wearing their own clothes. They enjoyed talking to the inspector and loved to be involved with the inspection. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 to 15. Service users were satisfied with their lifestyle in the home, and they had been able to exercise choice and influence decisions affecting them. Contact had been maintained with relatives and friends. Opportunities to access the local community had been made available. Catering aspects were very good with balanced nutritious meals being served with service user choice being noted. EVIDENCE: Contacts had been maintained, where possible, with relatives and friends and this was seen documented. Service users spoke to the inspector about their visitors. Short trips out to the community had been well organised and transport provided. The staff told the inspector about activities both inside and outside the home. Service users spoke of the places visited and also the entertainment within the home. Service users attended craft sessions and other activities. They said they enjoyed their meals and the choices offered. The menus and catering records had been examined in Weston House main kitchen and it was evidenced that the dietary requirements were being met. The newly appointed experienced cook was arranging the kitchen as preferred and changing suppliers to accommodate quality and value in the budget. Fresh fruit and vegetables were evident in the store as were home baked caked and pastries. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 13 The cook had been baking scones and preparing fresh vegetables during the morning and also baking in preparation for later in the week. The mid day meal had been enjoyed by service users. The staff spoke to each resident on a daily basis to establish his or her choice of food for the day, and this was seen documented. Service users were able to make a decision regarding choice of meal, and the inspector saw them being supported by staff who were knowledgeable of their individual likes and dislikes. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Complaints are listened to and resolved using the home complaints policies and procedures. Staff training protected service users from all aspects of abuse. EVIDENCE: An examination of the complaints book, the relevant policy and procedure documentation, and a discussion with staff evidenced that complaints and concerns were listened to and dealt with in the correct manner. Since the last inspection no complaints had been received. No incidents of neglect or abuse of any kind has been reported. The abuse policy documentation seen, and a discussion with staff confirmed that residents are protected from all forms of abuse. Documentation seen evidenced that the above issues had been discussed at length during staff induction, training and on-going supervision. During this transitional stage the new complaints procedure and relevant policies and procedures are to be introduced into the home. Once the management and staff are familiar with the details the service users, relatives and representatives are to be informed of the changes. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 22 and 26 Queensway House provides a safe and adequately maintained environment for service users. The home was clean and tidy, and had a very comfortable atmosphere. EVIDENCE: A tour of the building, including a check on the maintenance documentation, confirmed that the home was fit for purpose, clean and tidy. The duty rosters evidenced that adequate ancillary staff were employed. Staff when asked told the inspector of their knowledge on infection control, and showed him the relevant documentation. Adequate hand washing facilities were available throughout the home. The records evidence that maintenance of the premises was now being given priority. Painting and re-decorating was planned to continue. The lounge/dining area was tidy and well used. Emergency lighting and fire alarm tests were seen up to date and correct. There are no outstanding issues known from the Fire Prevention or Environmental health departments. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. The assessed needs of service users had been met by an adequate number of suitably trained staff. Recruitment procedures had been correctly addressed which had contributed to the protection of service users. Staff training had been given priority. EVIDENCE: Staffing levels were being maintained as 1st April 2002 and following a discussion with the assistant manager and her staff it was agreed that the shift cover was above adequate for the existing service users needs. Training had been given priority and the training records of individuals were seen. The records evidenced that all staff had benefited from ‘in house’ and external training, which had covered the needs of the registered client group. Staff told the inspector that they had been encouraged to study. Training had been provided for staff in the awareness and management of dementia related conditions, and staff outlined this to the inspector. The homes recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. Staff asked stated that they had job descriptions and contracts of employment. Student nurse are now working in the home from the local university, supervised and supported by the senior nurses on the units. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 and 38. The home appeared to be well managed and quality assurance was in place. Financial aspects were correctly addressed and recorded with safeguards to residents. Health and safety issues had been given a high priority and managed well. EVIDENCE: The manager is to be registered with the CSCI in the near future. An interview date has been arranged for the beginning of September. The manager is half way through completing the NVQ 4 in management course and her assistant manager will be commencing the course in the near future. From observations made and following a lengthy discussion with the manager and several staff, it was evident that the home was being run in the interests of service users. Quality assurance, including feedback from residents and their representatives, was seen documented and MHA will be introducing new systems to document their quality audit. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 18 Documentation seen evidenced that the views of visiting professionals had also been established, and included in the review process. A check on the records and a discussion with representatives evidenced that all service users had the opportunity to handle their own finances and all residents and families had chosen to do so. Day to day monies of residents were checked and money held reconciled with the ledger. Inventories of valuables and belongings brought into the home were seen recorded. No health and safety issues were noted during this inspection, including a tour of the home. The documentation seen for checks and examination of plant and equipment was all correct and up to date. The manager and staff spoken to confirmed that health and safety issues are given a high priority. Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 4 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION 2 3 x 3 x x x 3 STAFFING Standard No Score 27 4 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 4 3 3 3 x x 3 3 3 Queensway House E51-E09 S63817 Queensway V239163 100805 Stage 4.doc Version 1.40 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 Regulation Requirement There were no requirements made at this visit. Timescale for action 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. 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