Inspection on 23/10/06 for Queenswood Care Home

This inspection was carried out on 23rd October 2006.

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

Queenswood Care Home 11/11/05

Queenswood Care Home 27/06/05

Queenswood Care Home 06/12/04

Queenswood Care Home 09/06/04

Queenswood Care Home 13/11/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Queenswood Care Home Cliffgrove Avenue Chilwell Nottingham NG9 4DP Lead Inspector Mary O`Loughlin Key Unannounced Inspection 23rd October 2006 10:00 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 Queenswood Care Home DS0000008735.V302612.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. Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queenswood Care Home Address Cliffgrove Avenue Chilwell Nottingham NG9 4DP 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) 0115 922 1037 0115 943 6245 home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Agnes Elizabeth Grognet Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11/11/05 Brief Description of the Service: Queenswood is a Methodist Care Home providing personal care and accommodation for a maximum of 41 older people. The home is located in a residential area, one mile from Beeston town centre. The home has a minibus that is used for the service users to access local facilities and for other outings. The home was built for the purposes of a care home and the two-story building has level access. It is totally wheelchair accessible throughout with a passenger lift and other adaptations. All bedrooms are single and have ensuite toilet and shower facilities. There are well-maintained and accessible gardens providing seating areas outside. The range of fees are: £384.00 to £476.00 Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted unannounced. The main method of inspection was case tracking, which involved selecting four residents and examining their care records. Case tracking is used to establish if the needs of the residents are being appropriately assessed by the home and their needs are being catered for. Discussions with 4 residents, and 3 staff formed part of the case tracking methodology. Indirect and direct observation of practice and interaction between staff and residents was also carried out as part of the inspection methodology. The inspector viewed some areas of the building that included the communal areas, 1 bathroom, kitchen and four bedrooms. The garden area was also viewed. Residents were observed taking lunch. Other documentation including health and safety records were also examined. The management of medication was assessed for four residents. During the course of the inspection the Inspector spoke with four residents, the feedback was positive about the level of care received. The senior carer assisted in the inspection process. Three members of staff were spoken with and three staff files were viewed. The focus of the inspection was to concentrate on the key standards, which were assessed under the new methodology of Inspecting for Better Lives (IBL). 16 responses were received from the Commission for Social Care Inspection pre-inspection surveys sent to the residents. These responses were used to inform this report. Residents were seen to be happy and interacting with each other and the staff What the service does well: The inspection considered that good quality of care was provided for people using the service. The key National Minimum Standards are met and some areas clearly exceeded. Policies, procedures and practice guidance focus on residents being in control of their life. The home have appointed an activities coordinator who is responsible for creating meaningful activities and experiences both in the home and the wider community. Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 6 The home has a sustained track record of delivering good performance and managing improvement. As areas for improvement have emerged the service has recognised and managed them well since the last inspection. There is a commitment to promoting person centred care that ensures residents are placed at the heart of the service. It is a very well maintained, attractive home, which is accessible to community facilities and services. It has the specialist equipment and adaptations needed to meet individual residents needs. The changing needs of residents are met; along with their specialist care needs. It is fully accessible throughout to people with physical disabilities, adaptations and specialist equipment are designed to be as unobtrusive as possible and fit within the domestic, homely environment. Staff have been trained in adult protection and there have been no complaints and allegations received by the Commission about the service. There is a suitably trained staff team ensuring that the residents are in safe hands at all times. Residents’ comments were very positive and they described: “I’m enjoying living at Queenswood, I consider it is now my home and I’m alright” “Care staff are very helpful” “There is always someone around and nothing is too much trouble” “ I don’t have to wait long for assistance when I use my nurse call bell” “ I feel safe here” What has improved since the last inspection? What they could do better: Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 7 No requirements or recommendations have been made as a result of this inspection. 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. Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 8 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 Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 9 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): 3-6 Quality in this outcome area is excellent. This Judgement is made using available evidence including a visit to this service. The service considers carefully the needs assessment for each prospective resident before agreeing admission to the home. Prospective residents and their family, always have the opportunity to visit and spend time in the home prior to agreeing admission. Intermediate care is not provided at the home. EVIDENCE: The home has a sustained track record of meeting this standard. This inspection found that the records of three residents identified that they received a comprehensive assessment that exceeded the national minimum standard, prior to admission to the home. The service is highly efficient in obtaining a summary of any assessment undertaken through the care management arrangements and insists on receiving a copy of the care plan. A personal profile was completed for all three, and each prospective resident and their representatives had been consulted throughout this process. Queenswood Care Home DS0000008735.V302612.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): 7-8-9-10 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. The health and personal care, which a resident receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Robust medication systems ensure the safety of residents. EVIDENCE: The records of 4 residents were examined and each contained a comprehensive assessment of their need based on a person centred care planning system. Each resident has a plan that has been agreed with him or her. This is written in plain language, is easy to understand and considers all areas of the individual’s life including health, personal and social care needs. The plan also includes a risk assessment. The plans included a risk assessment for falls and evidence was seen of involving residents in a falls prevention day at the home, which is excellent practice and exceeds the National Minimum Standard. Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 11 The evidence shows that each resident’s plan is reviewed regularly and involves the resident and where agreed their family. The plan is updated and the necessary action taken to respond to any changes. Evidence was seen of quality assurance systems confirming that staff were completing the required care plans and necessary reviews. Residents have right of access to health and remedial services, commenting on their access to these services within written responses to the Commission. The health care needs of those residents too frail to leave the home are managed by visits from local health care services. Residents’ personal aids are well maintained and the home provides the necessary aids and equipment to support both staff and residents in daily living. Residents have individual health care plans that give a comprehensive overview of their general health and acts as an indicator to changing health needs. The medication policy was examined; it was efficient and supported by procedures and practice guidance. A quality assurance monitoring system has just been introduced to look at the management of medicines in the home, which is good practice. The medicine administration records of 4 residents identified very good practice in the recording into the home, on administration and drugs removed from the home. The storage of medicines was suitable and in accordance with the Medicine Act 1968. The treatment room was maintained to an excellent standard, all the necessary checks for the control of safe temperature storage were in place. The room was clean, tidy and very well organised. Clinical waste collection was in place and sharps disposal provided. Residents who have the capacity are encouraged to keep and take their own medication. The service provides information to residents on the core principles on which the care is based, underpinned by the mission statement to improve the quality of life for older people. Staff attitude during this inspection was caring and respectful, residents commented on how they feel relaxed and able to talk to staff about anything that they feel a need to. The home has a Chaplin who was visiting the residents and chatting to them during the morning. Induction training for all staff was seen to include privacy and dignity. Queenswood Care Home DS0000008735.V302612.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): 12-13-14-15 Quality in this outcome area is excellent. This Judgement is made using available evidence including a visit to this service. Residents have a lifestyle in the home that matches their expectations and preferences. Residents are able to maintain contact with their relatives and friends and the local community as they wish. Residents are able to exercise choice and control over their lives. A wholesome, appealing and balanced diet is provided at suitable times and in suitable surroundings. EVIDENCE: Residents were seen to be able to lead a full and stimulating lifestyle with a variety of options to choose from. Each resident is provided with information and reminded daily about the activities available at the home. Notice boards display a full list in large print of forthcoming events that residents can choose to participate in. One resident said they were able to go out and visit family each weekend and described how she continues to live an active life both inside and outside of the home. Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 13 There is an activities person employed, this exceeds the National Minimum Standard, who prepares a full programme of individual and group activities. These activities were seen to be meaningful and suitable for the resident group. Each resident has an individual social/recreational assessment along with a plan of care. Staff record information on the previous lifestyles and preferences of the residents to enable them to support the resident to maintain their choices and preferences. There is opportunity for people with visual impairment to participate in a group that provides them with large print games and materials for recreational purposes. The home has its own chapel and visiting minister. Services are held which are ecumenical and all faiths are welcomed. Residents confirmed their attendance at these services. The service recognises the importance of maintaining the involvement of resident’s relatives and friends. Residents said they are able to see their friends and relatives at any time. Evidence was seen that staff had maintained contact on a regular basis with relatives living in other countries, by email facility. Relatives meetings are also organised to enable them to contribute their ideas to the running of the home. The dining room was extremely well organised during lunchtime, the tables were set and each resident had a place setting at their table. Separate dishes of vegetables and sauces were placed on the table to encourage residents to assist themselves to whatever they chose. Staff were discreetly on hand to assist and were seen to do so in a sensitive way. The meals provided were considered balanced and nutritious with choice available at each mealtime. Breakfast is served in the small well-equipped kitchen areas around the home and residents said they enjoyed this mealtime with small gatherings of friends at the start of their day. This facility exceeds the National Minimum Standard. Queenswood Care Home DS0000008735.V302612.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): 16-18 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. Residents and people using the service can be confident that their concerns or complaints will be listened to and acted upon. Residents are protected from abuse. EVIDENCE: The home has a clear complaints procedure that is available to people who use the service. Clearly displayed within the main areas of the home a copy of the procedure is also provided to all residents and prospective residents of the home. The Commission has not received any complaints about the service since the last inspection. The records of concerns expressed to the home were viewed and seen to be addressed in an appropriate timescale. The concerns had been addressed sensitively and suitable actions taken to address any shortfalls in the home’s practices were seen to have been undertaken. The home has suitable policies in place to protect residents from abuse. Staff files demonstrated that all staff receive training in prevention of abuse and the protection of people who are considered vulnerable. There were no physical restrictions in place for the resident’s case tracked and no evidence that staff use any physical restrictive interventions. Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 15 All residents spoken with said they felt safe and well cared for, able to live as independently as possible and without any restrictions on their freedom. Residents are aware that staff hold records such as care plans that they can access if they wish. Residents spoken with said they managed their own finances and had advocates supporting them. Pre-inspection information received shows that residents are in full possession of their personal monies to spend as they wish. Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 16 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): 19-26 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. Residents live in a safe well-maintained environment. The home is clean pleasant and hygienic. EVIDENCE: The service provider demonstrates within the statement of purpose that layout of the home is suitable for the needs of the residents. The home provides a designated area, the Chapel, for resident’s quiet reflection and worship. The home was very well maintained throughout, comfortable and safe. All areas are accessible to residents with ramps, passenger lifts and stair lifts incorporated into the home’s interior as required to ensure the mobility needs of the residents are met. Residents said the home is always clean and tidy and all loved their own individual ensuite rooms. Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 17 The building is inspected by the local Fire and Environmental services and the Commission have not been informed of any outstanding compliance in these areas. A modern fire alarm system is incorporated in the building. The home has a suitable procedure for controlling infection and staff received training in infection control during 2006. Suitable laundry facilities ensure clothing is appropriately washed at suitable temperatures to control infection. The previous inspection required work to be undertaken on the provision of window restrictors, the home’s handyman confirmed that this work has being trialled and now considered successful, is to be rolled out to all the windows not yet conforming to this standard of safety. Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 18 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): 27-28-29-30 Quality in this outcome area is excellent. This Judgement is made using available evidence including a visit to this service. Residents are cared for by suitably trained staff and in sufficient numbers to meet their needs. Robust recruitment procedures are in place to protect vulnerable adults from people who may be unsuitable to provide care for them. Suitably trained care staff ensure that residents are in safe hands at all times. EVIDENCE: Staff files were seen and show that the home has a well developed recruitment procedure that safeguards residents from those that may be unsuitable to work with vulnerable adults. Staff files were examined and confirmed that all appropriate safeguards are in place. Duty records were seen and show that sufficient numbers of staff are employed to meet the needs of the residents. Residents felt staff were knowledgeable and in sufficient numbers to meet their needs. The home was well maintained and records suitably completed which demonstrate that staff are able to meet the full responsibilities of their role. New staff receive induction training and these records were seen. Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 19 Over 50 of the care staff are trained to level 2 in National Vocational Qualifications, which exceeds the National Minimum Standard. There is a low turnover of staff noted within the information provided to the Commission. All staff have a programme of learning and records of staff training during 2006 were clearly meeting the minimum standards. Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good. This Judgement is made using available evidence including a visit to this service. There is a competent registered manager. A quality-monitoring scheme is used to seek views about the service and actions are taken to improve the service. Systems are in place to protect service users from financial abuse. The health, safety and welfare of the residents and staff are promoted and protected. EVIDENCE: The manager is experienced and registered with the Commission. She has attained National Vocational Qualification level 4 in care and holds the Registered Managers’ award. Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 21 The last inspection considered the arrangements for quality assurance to exceed the national minimum standards. The Residents’ Survey is undertaken once a year and the forms, entitled “Seeking our residents’ help – Compliments, complaints & Comments”, are circulated and feedback provided to those participating. There are quality audits undertaken in all areas of health and safety in the home with records held. Residents are provided with lockable facilities in their room for keeping small sums of money. The home has more secure facilities if required in which to store monies and valuables, this was inspected at the last inspection to the home and suitable records were being held that safeguard residents from financial abuse. Staff ensure that residents are referred for legal or financial advice and most residents were seen to have people acting for them in this behalf. The records of fire precautions were examined and show that there are adequate precautions against the risk of fire including the provision of suitable fire equipment. Weekly fire tests are recorded, and equipment checks undertaken monthly. Fire risk assessments are in place. Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 22 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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement 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. Refer to Standard Good Practice Recommendations Queenswood Care Home DS0000008735.V302612.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Queenswood Care Home DS0000008735.V302612.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!