Inspection on 18/04/05 for Queensway House Residential Care Home

This inspection was carried out on 18th April 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Queensway House Residential Care... 11/09/07

Queensway House Residential Care... 25/04/06

Queensway House Residential Care... 15/02/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Queensway House Residential Home Jupiter Drive Hemel Hempstead Hertfordshire HP2 5NP Lead Inspector Pat House Unannounced 18 April 2005 10:00 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 Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Queensway House Residential Home Address Jupiter Drive Hemel Hempstead Hertfordshire HP2 5NP 01442 266088 01442 261818 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) Queensway Care Home Limited Mrs Marie Shouler Care Home 60 Category(ies) of A Alcohol dependecy past/present 1 registration, with number DE(E) Dementia over 65 60 of places MD Mental Disorder 1 OP Old Age 60 PD(E) Physical Disability over 65 60 Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: The category MD will be conditional on the continued occupation of a (named) service user. Date of last inspection 21/10/04 Brief Description of the Service: Queensway House is a sixty bedded care home for older people, who may also have a physical disability or dementia. The home does not provide nursing services. The building is two-storey and has a passenger lift. Service users have access to all parts of the home and gardens. Bedrooms are spread across both floors and there is currently no separation of facilities for those with a dementia and those who are not confused. All bedrooms are single occupancy and have en-suite facilities. The main dining room is on the ground floor but each floor has its own lounge. There is a large, secure garden to the rear of the home and a parking area at the front. The home is situated in a residential area, near to the town of Hemel Hempstead which has extensive shopping areas, leisure facilities and good transport links. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place during one working day. Two inspectors were present and a large number of residents were spoken to, as well as staff and visitors to the home. There was no Manager present in the home on the day of the inspection and two senior carers were providing management cover, as well as providing care as part of the care team. Subsequent to the inspection, the CSCI was sent a copy of the minutes of a recent staff meeting and this noted staff concerns, which were the same as some of the concerns raised by the inspectors at the end of their visit to the home. What the service does well: What has improved since the last inspection? What they could do better: There are Requirements and Recommendations made in this report, for every area inspected and the large numbers indicate that serious improvements and changes need to take place at the home. The home has suffered from a lack of continuity of management in the past year and reasons for this also need addressing. Procedures for covering staff absences do not appear to be adequate and most people spoken to indicated there were often staff shortages at the home. The management must ensure that all staff receive essential training and this includes training in the provision of activities, especially for those with dementia. It was felt by the inspectors and most staff spoken to that the residents would now benefit from some separation of services and activities provided for those with a dementia from those who do not have this diagnosis. The numbers of falls and accidents remains high at the home and this situation should be monitored by management. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 6 The recording made in service user care plans also needs development. Some shortages in food supplies were noted and much of the linen in the home appears to need replacing. There was also evidence that there are regimes attached to mealtimes, which are not to the benefit of residents and should be reviewed. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 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 Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 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) 3 and 4 Prospective service users have full assessments completed, to ensure the home can meet their needs. Currently the home is not demonstrating that it can adequately meet all the needs of service users. EVIDENCE: Service user records examined showed that detailed assessments were completed before individuals were admitted to the home and care plans had been produced in all cases. There was one service user in the home who had been re-assessed as now needing nursing care and was awaiting transfer to another home. Most of the staff spoken to on the day had received no dementia training and could not demonstrate that specialised activities were provided for those in this category. Service users who were not confused and some visitors spoken to indicated that, because there was no separation of confused and not-confused residents, individual needs were also not being met by the home. These issues have been detailed in the Evidence for Standards 12 and 30. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 9 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 and 9. Service users details are accurately recorded on individual plans to ensure appropriate care is given. Shortfalls in recording and procedures in the home mean that it cannot be demonstrated that all health care needs are being met or that medication is being administered safely. EVIDENCE: All service user records examined had care plans providing detailed information about the individual and their needs. There was evidence of regular reviews taking place and most plans were signed by the service user or their family. There were some risk assessments in place but generally these need to be developed, especially regarding the prevention of falls and where the actions of individuals are putting them at risk. Records showed that service users have regular contact with dentists, the chiropodist and the optician and the doctor had been called to the home on the day of the inspection and said she was regularly contacted to visit residents. Service users generally praised the care provided by staff at the home, but said that they were often rushed as there was sometimes a shortage of staff. One service user seen had not been shaved, although he said he had wanted to be, and one or two residents looked unkempt. Details of the treatment and progress of pressure sores were not recorded in care plans. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 10 Staff said that visiting nurses do not generally let them know about progress or even that they are in the home on some occasions (See standard 38). Although adequate records were not being kept in all cases, the care provided by staff, where service users were unwell, was clearly very good. One service user who was awaiting a transfer to nursing care was having hourly checks from care staff and was seen being fed. There were also fluid charts in place where appropriate. Staff said that service users were often referred to the Falls Clinic through the G.P. At previous inspections it was recommended that training is provided at the home in the prevention of falls, this advice remains. It was also recommended previously that the incidence of falls and accidents in the home is monitored, as numbers concerned were, and continue to be high. The home has a written medication policy and requirements made at the last inspection, regarding the administration of medication were generally being implemented. However, there was one bottle of Paracetamol with a written “Homely Remedy” label on, which had no date of opening and which could not be audited. Staff spoken to were also not sure if the home had a policy for “non-prescribed drugs.“ Records for medication brought into the home with new residents were well documented, but written entries should have two staff signatures to ensure accuracy. There were some non-blistered packets of medication which did not tally with amounts recorded and some gaps on the MAR charts. It appeared that most errors occurred at night and, on examining staff rotas and training records, it appeared that one care worker giving medication at night had received no medication training. An Immediate Requirement notification was left at the end of the inspection to ensure service user safety. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 11 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, 13 and 15. The current activities provision in the home is failing to meet the expectations of service users and their families although family contact is encouraged for the benefit of all. The meals provided are generally good but the times are not always convenient to residents and there are shortfalls in the provision of snacks, which are of concern to some service users and staff. EVIDENCE: The home has an activities co-ordinator who works from Monday to Friday and alternate Saturdays, from 10a.m. until 4p.m. Because there is no separation in the home between those who have dementia and those who do not, staff said that all activities provided are offered to all residents. Staff, service users and visitors were questioned about this provision, and most felt that it was unsatisfactory. Service users who were not confused said that they did not always join in activities as the more confused residents prevented a successful event taking place and some visitors spoken to said they always found their relatives asleep when they called and were not aware of “much going on” in the home. Recently the co-ordinator had been seconded to help at another home. Service users said that other care staff had not had time to provide adequate activities in her absence. One service user said that she went outside and smoked a lot “as there is not much else to do.” Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 12 Minutes seen of a recent staff meeting noted staff concerns about the lack of toiletries available for residents, as the home’s “shop”, from which toiletries were normally supplied, was out of stock. The minutes state that most of the snacks in the shop were also out of date. The minutes noted that the activities co-ordinator had been “doing care work for the last 7 weeks” and so there had been no activities provided and the shop had not been re-stocked. During the inspection, there was loud music playing in the lounge areas and some music was clearly more appropriate for staff than elderly people. On the downstairs notice board, forthcoming trips out were advertised, but there were no details of daily activities. In the upstairs lounge, games were being played at one point in the day, however there were only six residents taking part together with three members of staff. Records indicated that no specialised training has been provided for staff in the provision of activities for those with dementia and such training would seem to be essential. It is also strongly recommended that the Manager considers the apparent need to make separation in the care and provision for service users with dementia and for those who do not have this diagnosis. Visitors spoken to confirmed that they are welcomed in the home at all times and that there are no restrictions placed on visiting hours. They said they could speak to their relatives in private, in their bedrooms, or in communal areas. The mid-day meal was seen served in the dining room, and in individual bedrooms. There is no choice of main meal offered, although an alternative omelette or salad can be provided if the meal is refused. Service users generally said they enjoyed the meals and on the day the food looked hot and appetising. However, staff said that once the kitchen “closes”, snacks have to be provided from the kitchenettes on each floor, and said there was often not enough food, such as biscuits, milk, tea and sugar supplied. Service users confirmed this shortage and said there were also no teaspoons to use. Staff said that there was a time “deadline” for service users to arrive in the dining room for breakfast, after which the doors were closed. Staff said that often, they could not get all the service users ready in time to meet this deadline. Some of the food stored in the kitchen was not dated on opening, and this included “left-over” food from breakfast, which was to be used the following day. Bread in the freezer was also not dated. On the day of the inspection, food supplies were quite low, with little fruit available and no fresh vegetables. The cook said a food delivery was due the next day. Fridge and freezer temperature checks were being completed. There appeared to be a water leak under one counter and some wall tiles needed cleaning. The kitchen vents were also dirty and had apparently not been cleaned since November, although this maintenance is planned for every month. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 13 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. Service users and families are provided with details of the homes complaints procedures which confirm that all issues will be adequately dealt with. The home has policies to ensure service users are protected from abuse, but there have been recent shortfalls in implementing these procedures. EVIDENCE: The home has a written complaints policy, which sets out clear time-scales for responses and which gives details of the CSCI. Copies of this policy are given to all service users and can be seen displayed on one of the home’s notice boards. Records are kept of all complaints made, with details of the subsequent investigations and actions. The home also has written policies on Adult Protection and Whistle blowing. However, there was no evidence that staff have received training in Adult Abuse prevention and those spoken to were not aware of current guidelines. A recent incident in the home was handled appropriately by the manager and the CSCI was informed. However, the resulting need for special staff supervision had not been adequately implemented, and an Immediate Requirement notification was left at the end of the inspection. The system for managing service users’ monies has been checked previously and was sound this will be checked again at the next inspection. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 14 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, 21, 23, 24, 25 and 26. The home provides adequate facilities to enable service users to live comfortably and safely, although some areas of repairs and maintenance need improving to ensure standards are kept at satisfactory levels. EVIDENCE: The home was generally clean on the day of the inspection, although some areas were in need of re-painting. One bathroom was out of action waiting for repairs and some areas in the kitchen were in need of attention, as already described. Quite a few of the carpets in the home were dirty and stained and were becoming smelly. Sufficient communal areas are provided for service users in the home, although there is no dedicated smoking room, residents and staff were sitting outside to smoke during the day. There are sufficient numbers of bathrooms and toilets in the home to meet the needs of all the residents. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 15 The home meets the space requirements for bedrooms and communal areas and none of the bedrooms are shared. Bedrooms in the home are well furnished and many residents have brought their own furnishings and belongings with them. Bedroom doors are fitted with locks and some service users were seen locking their doors when they left their rooms. However, some of the bedding seen in service users’ rooms was in need of replacing, this included sheets, pillows and special incontinence bedding. Service users confirmed that there was adequate heating in the home and radiators have low temperature surfaces to ensure safety. There is emergency lighting in the home and hot water was being delivered at safe temperatures in all areas checked. Staff confirmed that, where appropriate, red bags were used to wash laundry separately, and the washing machines have high temperature settings to meet disinfection standards. Disposable gloves were clearly available to staff and the laundry was clean and uncluttered when visited. However the sluice on the top floor had not been working for some time and staff said they were carrying waste matter to the other sluice down the stairs which service users and visitors use. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 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, 29 and 30. Sound recruitment procedures are now in place which help to protect service users in the home, but the numbers of staff at the home sometimes fall below the amount needed to ensure all residents needs can be met. There are shortfalls in the practice and recording of staff training which detracts from the efficiency of staff employed. EVIDENCE: On the day of the inspection two senior carers were sharing the responsibilities of managing the home and were also providing care for service users. There were an additional 8 care workers on duty in the morning and 6 in the afternoon. The activities co-ordinator was working and there was a cook and kitchen assistant providing meals and 3 domestic assistants also on duty. 5 care workers were on the night staff rota. 1 member of staff due to work in the laundry, was absent, and one of the care workers was covering her duties, meaning that only 7 staff were providing care for service users that morning, apart from the seniors. 2 administrative assistants were also working in the office. Service users spoken to said that the home was short-staffed at times, and felt they were sometimes rushed. Staff numbers on the day appeared to be barely adequate. Staff said that the home’s policy was that agency staff were generally not used and that the procedure for asking existing staff to cover for absences was lengthy and therefore did not immediately cover for shortfalls. It was noted however that the two seniors on duty were providing excellent care to the residents, and those service uses spoken to said that these seniors also dealt with all their problems and were always available. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 17 One or two residents thought that one of the seniors was actually the Manager. The staff rotas examined indicated that there was often no senior on duty at night and that care staff numbers often fall to fairly low levels in the day. The rotas also indicated that one care worker, employed on a student visa, was working more hours than the visa permitted. Recruitment records examined showed the required staff checks had been made and documented. Staff at the home have clearly worked hard to introduce new recruitment procedures and forms and there is now a sound system in place. Staff training courses have been booked for the near future, including Infection Control, Dementia, Foot Care, Continence Management and Care of the Deceased. However, many of the staff who had worked at the home for some years, said they had not received any training in Dementia Care or Adult Abuse Procedures and some had not had Moving and Handling updates for some time, although this training was now underway. The care worker covering the laundry said she had had no training in Infection Control. There were no records available of any staff Induction Training and no overview of staff training to show the courses staff had undertaken. As already noted, there was also training shortfalls for night staff. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 18 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) 32, 36 and 38. The day to day running of the home has been compromised by the changes to, and absence of, consistant management in the home and this has been to the detriment of service users. The resulting staff concerns and areas needing attention are impinging on the welfare of service users. EVIDENCE: There have been several changes of Manager in the home in the past year and senior staff should be commended for maintaining the continuity of the main procedures for the residents’ care. However, there are clear indications that all standards are not being maintained in the home, as already described in the report. Dates of Residents’ Meetings were displayed on notice boards, although one had been cancelled, and staff confirmed that staff meetings are held. However, many of the care staff spoken to, said they were unhappy with aspects of the day to day running of the home, and the minutes of a recent staff meeting noted serious concerns expressed by staff. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 19 Some staff confirmed that they receive formal supervision, although the frequency varied, whilst others said supervision had been omitted through lack of staff time. As already noted, essential supervision for one care worker had not taken place, although this was part of ensuring service user protection. Some staff said they have had concerns about infection control issues at the home, especially regarding the control of MRSA. The procedures in operation were in fact quite thorough, but the concerns highlighted the need for more staff training in this area. As also noted, one sluice in the home must be repaired as soon as possible. During the inspection one care worker was observed using one cloth to clean various chairs, some of which had been recently soiled, and attention was drawn to the risk of spreading infection from the process. The minutes of the staff meeting also highlighted staff concerns about poor standards of room cleaning in the home and restrictions on putting utensils through the dishwasher, to ensure any infection is controlled. Some residents’ doors were being wedged open during the inspection, but staff confirmed that magnetic door openers had been delivered for these doors and would soon be fitted. Equipment in the home had been serviced within the year and fire equipment is regularly checked. In the ground floor kitchenette, used by service users and visitors, there were COSHH products stored in an unlocked cupboard. In the same room the supplies of powdered milk and spread were some years out of date. During the inspection a lot of people were seen entering and leaving the home without speaking to care staff and it was confirmed that district nurses often visit without staff awareness. There is no keypad or lock on the main door and this door is not secured until 8p.m. This situation would appear to put service users and staff at unnecessary risk. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 3 3 x 3 2 3 3 STAFFING Standard No Score 27 2 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x 2 x x x 2 x 2 Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 21 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 8 Regulation 13(4)(b)& (c) Requirement The Registered Provider must ensure that detailed risk assessments are in place for all service users at risk of falling and that falls and accidents in the home are monitored. The Registered Provider must record and review the treatment and outcome of all pressure sores in the appropriate individual care plan. The Registered Provider must ensure that a written procedure for administering and auditing non-prescribed medication is followed, that two staff sign any hand-written instructions and that only properly trained staff are involved in medication administration. The Registered Person must provide separate recreational activities which suit the needs of service users with a dementia and those without. The Registered Person must provide enough fresh food and supplies for the use of service users after the main kitchen is closed. The Registered Person must Timescale for action 1st August 2005 2. 8 15(2)(b) 17(1)(a) Schedule 3 (3)(n) 13(2) 1st August 2005 3. 9 18th April and henceforth. 4. 4 12 16(2)(n) 1st August 2005 5. 15 16(2)(i)&( h) 18th April and henceforth. 18th April Page 22 6. 15 13(3) Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 7. 18 13(6) 8. 18 13(6) 9. 10. 19 19 23(2)(d) 13(3) 11. 24 16(2)(c) 12. 27 18(1)(a) 13. 30 18(1)(c) (i) 14. 15. 30 36 18(1)(c) (i) 18(2) ensure that stored foods are labelled with dates of purchase and dates of opening. Food which is out of date is disposed of. The Registered Person must ensure that all staff receive training in current procedures for preventing Adult Abuse. The Registered Person must ensure that supervision procedures, introduced to respond to the suspicion of abuse in the home are followed. The Registered Person must clean or replace all the stained and dirty carpets in the home. The Registered Person must repair or replace the broken sluice so that waste matter is not carried round the home. The Registered Provider must replace all worn sheets pillows and incontinent bedding in the home. The Registered Provider must ensure there are always sufficient numbers of trained staff on duty in the home, including senior staff working at night and that procedures for covering staff absences in a timely manner are satisfactory. The Registered Provider must ensure that evidence of staff induction training is available and that all staff receive foundation training within the first six months of appointment and receive regular updates where appropriate. The Registered Provider must provide Dementia training for all care staff working in the home. The Registered Provider must ensure that care staff receive appropriate formal supervision (the NMS state at least six times and henceforth 1st August 2005 18th April and henceforth 1st July 2005 1st May 2005 1st July 2005. 18th April and henceforth 18th April and henceforth 1st September 2005 18th April and henceforth. Page 23 Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 a year). 16. 38 13(4)(a) & (e) The Registered Provider must provide a secure entry system for the home. 1st July 2005. 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 15 30 Good Practice Recommendations The Registered Provider should ensure that meals, and especially breakfast, are provided at flexible times, so that service users are not rushed. The Registered Provider should ensure that all staff have an individual training profile and that there is a staff training overview maintained in the home to ensure all staff receive appropriate training. The Registered Provider should ensure that service users and staff understand and are satisfied with the management situation in the home and that a new Manager is appointed as soon as possible. 3. 32 4. Queensway House Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Herts AL7 3BQ 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 Residential Home I52 S63303 Queensway V221774 180405 Stage 4.doc Version 1.20 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. 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