Inspection on 26/09/06 for Queensway House

This inspection was carried out on 26th September 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 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 28/02/06

Queensway House 10/08/05

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 Mrs Joanna Wooller Key Unannounced Inspection 26 September 2006 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queensway House Address Weston Road Stafford ST16 3UQ 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) 01332 296200 home.fxg@mha.org.uk Methodist Homes for the Aged Janet Marie Coulston Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (22) of places Queensway House DS0000063817.V308760.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 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 rehabilitation-orientated 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 GPs, community nurses and a pharmacist. Consultant psychiatrists and psychologists undertake domiciliary visits on a regular basis. Fees Low £ 546 High £672 Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Lead Inspector, Joanna Wooller, carried out this unannounced Key Inspection. The visit was commenced at 11.00 and the Inspector met with the home manager on arrival. There were 22 Service Users in the home and 5 care staff was on duty including one Registered Nurse, plus the Manager, Jan Coulson. The Shift Team Leader accompanied the Inspector and the manager for the visit. The inspector evidenced care records, all necessary documentation and inspected the homes environment, including the individual flat kitchens, the satellite kitchen and the Service users bedrooms. Service Users who were moving around the home freely and they chatted to the inspector. Several Service Users were joining in a game of bingo and flowers had been purchased for a session of flower arranging. The environment was generally clean and clutter free but the inspector noted several areas that required a deep clean including the satellite kitchen and some bedrooms. Feedback cards received were complimentary about the service and the staff. Comments included: “My relative is well looked after and her carers go beyond the call of duty to look after her.” “Highly professional and well trained staff, nursing care is of the highest standard. Fully integrated into local services including community Health Team. Always willing to go the extra mile for Service Users, carers and professionals.” “A very valuable resource and service.” “We are very satisfied with the care our son receives at Queensway House.” Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 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 DS0000063817.V308760.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 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 the following standard(s): 3 Quality in the outcome area is good. This judgement has been made using the evidence available including a visit to the service. The information available in the Statement of Purpose ensures the service users and their representatives have the appropriate information to make an informed choice. EVIDENCE: The Statement of Purpose identifies the company that owns the home, MHA. The MHA policies and procedures are continually being introduced into 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 those parties involved had the opportunity to visit the home prior to choosing to stay. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 9 Community care plans if available were provided by the social worker and used, as part of the individual needs assessment process. The records seen and a discussion with the staff evidenced again that care staff, individually and collectively, had the necessary experience and skills to meet the assessed needs of the current service users. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 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 the following standard(s): 7 to 10 Quality in the outcome area is adequate. This judgement has been made using the evidence available including a visit to the service. Service users health care needs are identified and appear to be met whilst in the home, however the care records were not up to date and did not always reflect the current condition of the Service User. Medication policies and procedures were adhered to. EVIDENCE: Of the three Service Users case tracked the care records were not up to date and did not reflect the current condition of the Service Users. Assessment reviews had not been completed and although risk assessments were in place they had not been reviewed. Individuals past history and social preferences were documented. The inspector evidenced one gentleman in particular in his flat who was very settled and happy in the home but his care documentation did not reflect this in the individualised way that it should do. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 11 Social care plans must be introduced to ensure that the activities the Service Users perform are suitable, rewarding and the named nurse is fully aware of the individuals needs being met. No issues relating to medication were raised and the policies and procedures that are in place support this task. Evidence of Service Users being shown respect was visible to the Inspector and Service Users individual’s dignity was preserved. Staff were seen to discreetly support the Service Users and offer assistance as required. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 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 the following standard(s): 12 - 15 Quality in the outcome area is good. This judgement has been made using the evidence available including a visit to the service. Service Users have access to a range of appropriate activities. The daily routines are established to maintain independence, choice and freedom within their home. The meals that are provided are nutritious, balanced and varied promoting Service Users health and well-being. EVIDENCE: The Service Users plan their activities with the staff and their individual likes and hobbies are considered. Service Users are involved in appropriate activities enabling them to maintain social, emotional and independent living skills. Some Service Users become involved in educational and occupational activities to enable them to live a fulfilled life. Involvement in the local community is also encouraged if appropriate to their assessed needs. Daily routines are seen as flexible to acknowledge individuality and choice within their home. Tabletop activities continue in the home with artwork and crafts sessions being undertaken. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 13 Service Users arrange coffee mornings and staff from other areas of the home visit to join in the social event. Photo boards are sited in the home to display events and activities taking place which are updated as events occur. The experienced cook has now arranged the kitchen as preferred and suppliers have been sought to accommodate quality and value in the budget. Fresh fruit and vegetables were evident in the storeroom, which is supplied weekly. Freshly baked cakes and pastries are served daily. The menus are under review at present as some new dishes are less popular than others and this is to be rectified with Service Users input. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 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 the following standard(s): 16 and 18 Quality in the outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaints procedure is visible in the home and used as necessary by relatives and Service Users. Service Users legal rights and protection from abuse are supported through staff training and open management of the home. EVIDENCE: The Commission For Social Care Inspection had received no complaints since the last inspection. The complaints process and procedure remains in place at the home. Staff training is given relating to vulnerable adults procedures and abuse, which ensures staff are ware of the need to be vigilant for signs of abuse and they are able to report it. Individual legal rights are protected through family involvement or advocacy services. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 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 the following standard(s): 19 and 26 Quality in the outcome area is adequate. This judgement has been made using the evidence available including a visit to the service. Service Users do live in a safe well-maintained environment that is generally clean pleasant and hygienic. Some areas identified required a deep clean and some areas a refurbishment. EVIDENCE: On arrival to the unit the Inspector noted that the carpet was looking very worn and although the sitting area is very homely this also is showing signs of wear and tear. The satellite kitchen was a little unkempt and needed to be tidied up. Some paintwork identified needed repainting and freshening up. One lady had obviously spilt her drink whilst in bed and this had left sticky stains on the wall and paintwork, which had been overlooked. The bedrooms, which are well maintained with regard to furniture, require a deep clean to give a hygienic feel to the environment. Areas behind bedroom furniture had not been vacuumed and windowsills were dusty. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 16 Carpets in the hallways, staff office and lounge area were not to an acceptable standard of appearance and these must be changed. Refurbishment of the unit must continue. However the hall and stairs at the rear of the home were being decorated. The inspector also noted the domestic trolley left unattended in the doorway of a Service Users bedroom for approximately four minutes. This practice must be stopped to avoid untoward accidents. Toilets and bathrooms were clean and tidy and no issues were raised. Maintenance of the unit appeared satisfactory and in order. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 to 30 Quality in the outcome area is good. This judgement has been made using the evidence available including a visit to the service. The skilled staff ensure that they meet the Service Users needs. Service Users are supported and protected by the homes recruitments policies and practices. Staff training is suitable and well planned throughout the year. EVIDENCE: Staffing levels are monitored to ensure that the needs of the service users can be met. Staffing levels and staff competence are considered when staffing rotas are prepared. Most of the staff are first aid trained and have a food hygiene qualification. One trained nurse is on duty for each shift, supported by care staff. Each trained nurse has a responsibility to promote current good practice within the home. Staff training is recorded and monitored by the Manager and her deputy. The inspector was shown evidence of appropriate training being organised, and carried out. The manager arranges teaching sessions, which are appropriate and necessary for the staff working in the care setting. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 18 A robust recruitment procedure is in place, which demonstrates the managers’ commitment to employing and developing highly qualified and professional staff. Issues of diversity are covered in the NVQ training and the staff are fully aware of ways to record individual needs and ensure they are met. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 This quality outcome is good. This judgement has been made using available evidence including a visit to this service. The home continues to be run and managed for the benefit of the service users. The staff is suitably supervised and they and the service users are safeguarded by the policies and procedures in home. The health, safety and welfare of service users and staff are promoted. EVIDENCE: The ethos and leadership within the home is positive and open. The manager and her team are highly thought of by service users and their relatives/representatives. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 20 It was evident to the Inspector whilst in the home, that the home is run in the interest of the service users. Staff and relatives confirmed that the service users wishes and choices are promoted within the home. Financial issues were all satisfactory and policies and procedures protected service users financial interests. Staff supervision is now in place and up to date. The health, safety and welfare of staff and service users is promoted and protected by the rigorous testing, recording and monitoring of systems within the home. The maintenance person maintains the home in a professional manner and the records seen by the inspector evidence this. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 2 Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 13 (4a) Requirement Timescale for action 26/09/06 2 OP7 15 3 OP19 23(2d) 4 OP19 16(2c) The Registered person shall ensure that all parts of the home to which Service Users have access are free from hazards. The domestic trolley must be locked away when not in use. The registered person shall 26/10/06 ensure that the Service Users plan is relevant to their care, demonstrates the input given by the staff and is evaluated at least monthly to ensure that their needs are being met. The Registered person shall 26/10/06 ensure that all areas of the home are kept clean and reasonably decorated. The Registered person shall 26/11/06 ensure that rooms occupied by Service Users have adequate furnishings including floor coverings suitable to the needs of the Service Users. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 23 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 OP7 OP19 Good Practice Recommendations New MHA care documentation to be introduced and finalised in a timely manner. The homes refurbishment and redecorating programme must continue and be completed in a timely manner. Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. Extracts may not be used or reproduced without the express permission of CSCI Queensway House DS0000063817.V308760.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!