Inspection on 23/01/06 for The Queensmead

This inspection was carried out on 23rd January 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

The Queensmead 17/11/08

The Queensmead 19/12/06

The Queensmead 23/08/05

The Queensmead 21/02/05

The Queensmead 31/08/04

The Queensmead 19/12/03

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

CARE HOMES FOR OLDER PEOPLE The Queensmead Victoria Road Polegate East Sussex BN26 6BU Lead Inspector Kathy Flynn Unannounced Inspection 23rd January 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 The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 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. The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Queensmead Address Victoria Road Polegate East Sussex BN26 6BU 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) 01323 487931 01323 488120 Chanctonbury Healthcare Limited Mrs Madeleine Marshall Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is thirtyseven (37). Service users should be sixty-five (65) years or over on admission. Date of last inspection 23rd August 2005 Brief Description of the Service: The Queensmead is registered to provide personal care for up to 37 older people, over 65 years of age. The home is situated in a residential area of Polegate, it is close to the towns high street with shops, the library and public transport within walking distance. There is a large lounge that is used for social activities, a separate dining room, a conservatory at the front of the building and smaller seating areas near reception and on the first floor. A shaft lift enables residents to have access to all parts of the building and there are attractive gardens surrounding the home with seating areas and a parking area to the front of the building. The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second statutory inspection of the year and should be read in conjunction with the first inspection report that was carried out on the 23rd August 2005, to give an overview of all the standards assessed during this period. The requirements listed in the previous report were used to develop the plan for this inspection and the aim was to assess if the home had met the requirements, identify the aspects of the service that have improved, and how the service could be developed for the benefit of residents. This was an unannounced inspection carried out over three hours from 1pm and included an examination of care plans, training provision and policies and procedures, as well as discussion with residents and staff. There were 35 residents at The Queensmead during the inspection, a number were in the lounge preparing for the activity that had been arranged for that afternoon. Ten residents and a visitor were happy to talk about the support the home provides, and discussions about the services took place with the manager and the staff on duty. What the service does well: What has improved since the last inspection? The care plans have improved and staff have received some training, however this should be an ongoing programme to ensure that all care plans have the appropriate information concerning the assessed needs of residents. The homes recruitment procedures are now followed and include two references and CRB/POVA checks. The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 Page 6 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. The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 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 The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 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): EVIDENCE: Standards not assessed at this inspection. The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 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 the following standard(s): 7 There is no clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet residents assessed needs. EVIDENCE: A considerable amount of work had been done to improve the care plans at the home, however those viewed did not all contain the same amount of information. Clearly only some of the staff are recording sufficient information to enable staff to provide appropriate care and support. There is little evidence that residents and their relatives are involved in the care reviews. The manager confirmed that staff training will continue and the staffs ability to record the relevant information will be integrated into the formal staff supervision sessions that are being developed. The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 Page 10 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): EVIDENCE: Standards not assessed at this inspection. The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 Page 11 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, 17 and 18. The home has a satisfactory complaints system with some evidence that residents feel their views are listened to and acted upon. Adult protection training is not provided for all staff, therefore residents may not be protected from abuse. EVIDENCE: The Commission has not received any complaints regarding the care and support provided at The Queensmead. Appropriate policies and procedures are in place. Residents are able to take part in the electoral process, a number use the postal voting system. Adult protection training has been provided for some staff at the home, this should be extended to include all staff who work at the home. The manager confirmed that this will be arranged. The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 Page 12 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): EVIDENCE: Standards not assessed at this inspection. The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 Page 13 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): 30 Induction training does not enable new staff to provide appropriate care and support for residents. EVIDENCE: The manager confirmed that basic induction training is provided for new staff. This is to be developed in line with Skills for Care, and should be followed for up to twelve weeks to ensure staff are competent when providing support and care for residents. The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 Page 14 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): 35, 36, 37 and 38 Staff are not supported in their professional development through formal supervision, which may put residents at risk. Appropriate health and safety training for staff is provided which ensures that safe practices protect residents. EVIDENCE: The management of Chantonbury Healthcare Limited are working towards an effective quality assurance and monitoring system. Some aspects of the service are reviewed on a regular basis, including food provision, and the aim is to extend this with all of the services incorporated into the final documents. The Queensmead does not take responsibility for residents finances. Several look after their own while others have support from relatives or representatives. The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 Page 15 Supervision is provided on a day to day basis as part of the management process and the manager is developing a programme of formal supervision for all the staff. This will include group and individual sessions. Appropriate policies and procedures are in place, staff are expected to read these and a précis is included in the staff handbook. Staff sign to say that they have read these and understood them. Training in line with legislative requirements is in place and includes moving and handling and fire safety. A health and safety booklet is being developed and will be made available to all staff. There was some confusion regarding the requirement listed in the last report concerning the use of propping open residents doors. The manager was advised that residents were using stools, slippers and other implements during the inspection and that fire safety regulations state that this is not safe. Some of the residents’ rooms have appropriate safeguards in place and these should be extended to include all residents whose risk assessment identifies that they prefer to have their door open. The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 Page 16 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 3 3 2 The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 Page 17 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 OP7 Regulation 15(1) Requirement Training to be provided for all staff to ensure continuity of information is recorded in the care plans. Training in Adult Protection and whistle blowing to be provided for all staff. Induction training in line with Skills for Care to be provided for all new staff. A quality assurance and monitoring system to be developed and introduced. Advice to be sought, and acted upon, from the Fire Service concerning the use of safe systems of keeping doors to residents rooms open. Timescale for action 19/03/06 2. 3. 4. 5. OP18 OP30 OP33 OP38 13 (6) 18 (1) (c) (i) 24 13(4)(c) 19/03/06 19/03/06 26/03/06 23/01/06 The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 Page 18 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 The Queensmead DS0000021260.V261594.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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