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Care Home: Queen Elizabeth House

  • 38 Southborough Road Bickley Kent BR1 2EE
  • Tel: 02084673994
  • Fax: 02084677660

Queen Elizabeth House is a two-storey, purpose built care home for older people. The provider is Greensleeves Homes Trust. The home is set back from a busy main road, in a residential area. There is a bus stop outside the home and Bickley mainline rail station is within walking distance. The home is near to local shops. The building has parking space at the front and a garden at the back, with raised flowerbeds, lawn and patio.Queen Elizabeth HouseDS0000006962.V376084.R01.S.docVersion 5.2

  • Latitude: 51.396999359131
    Longitude: 0.045000001788139
  • Manager: Ms Asvinta Thakkar
  • Price p/w: -
  • UK
  • Total Capacity: 28
  • Type: Care home only
  • Provider: Greensleeves Homes Trust
  • Ownership: Charity
  • Care Home ID: 12646
Residents Needs:
Old age, not falling within any other category

Previous Inspections

This may not be the latest inspection for this service as we are having techinical problems updating from CQC - please check directly on the regulators website for the most recent report; bestcarehome hopes to be back to regular updates shortly.

For extracts, read the latest CQC inspection for Queen Elizabeth House.

Key inspection report CARE HOMES FOR OLDER PEOPLE Queen Elizabeth House 38 Southborough Road Bickley Kent BR1 2EE Lead Inspector Janet Pitt Key Unannounced Inspection 17th June 2009 10:00 DS0000006962.V376084.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queen Elizabeth House Address 38 Southborough Road Bickley Kent BR1 2EE 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) 020 8467 3994 020 8467 7660 qeh@greensleeves.org.uk www.greensleeves.org.uk Greensleeves Homes Trust Ms Asvinta Thakkar Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 28 25th October 2006 Date of last inspection Brief Description of the Service: Queen Elizabeth House is a two-storey, purpose built care home for older people. The provider is Greensleeves Homes Trust. The home is set back from a busy main road, in a residential area. There is a bus stop outside the home and Bickley mainline rail station is within walking distance. The home is near to local shops. The building has parking space at the front and a garden at the back, with raised flowerbeds, lawn and patio. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is three star. This means the people who use this service experience excellent quality outcomes. One inspector undertook this unannounced inspection. A site visit was made that lasted three and a half hours. During the site visit people who live in the home were spoken with. Discussions were held with members of staff and the manager. Observations were made of activities and mealtimes. Records relating to staff recruitment and training were examined. Assessments and care plans of the people that live in Queen Elizabeth House were inspected. We also had a look around the premises and its gardens, to see what facilities are provided for individuals. The home provided us with their Annual Quality Assurance Assessment (AQAA); information from this has been used to inform this report. The weekly fee at the time of inspection was £570 to £640 dependant on assessed need. What the service does well: The home’s AQAA indicates that they consider that ‘time is spent to discuss people’s needs and exactly what Queen Elizabeth House is able to offer.’ ‘Queen Elizabeth House goes to exceptional lengths to provide prospective residents with full information on the home.’ Queen Elizabeth House goes to great lengths to make sure that people are able to control their lives. The promotion and maintenance of independent living skills makes sure that individuals can lead a fulfilling life. The manager has high expectation of the staff team to provide a good quality of care. This challenge has been accepted by the staff and is evident in the care they give to each person. Queen Elizabeth House provides a homely environment for people to live in and they are able to influence the day to day running. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 6 Record keeping is excellent and show a person’s needs and how they should be met. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Queen Elizabeth House DS0000006962.V376084.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 Queen Elizabeth House DS0000006962.V376084.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that their needs will be fully assessed prior to and upon moving into the home. Sufficient information is available for an individual to make an informed choice about whether to live at Queen Elizabeth House. EVIDENCE: The home’s AQAA states: ‘Time is spent to discuss people’s needs and exactly what Queen Elizabeth House is able to offer.’ ‘A detailed care assessment is carried out, and includes reports from all disciplines ……in order to make an informed decision as to whether Queen Elizabeth House can meet the person’s needs.’ Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 9 We found that individuals are assessed prior to moving in. When we looked at peoples’ assessments we found that information from the placing authority and other agencies was present. People or their representatives had been involved in the assessment process. The manager carried out an assessment of need and this included information on a person’s medical and social history. The focus is on what an individual is able to do and how their independence can be maintained, for example ‘[they] need assistance to cut up food. Sometimes [they] eat with [their] hands but is able to use cutlery.’ Each person had a contract on file that detailed what is included in the fee. The manager told us that individuals are welcome to visit the home and have a meal with other people prior to making a decision about moving in. A member of staff is allocated to an individual if they chose visit Queen Elizabeth House for a day to see what the service can provide. Each person initially has a six week trial period before having to make a decision about whether they would like to live in Queen Elizabeth House. The home is hoping to involve individuals who currently live in the home in assisting with visits made by people who are looking to move into Queen Elizabeth House. Queen Elizabeth House DS0000006962.V376084.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that their care plan will reflect their assessed need. The individual or their representative is involved in the care planning process and a person’s wishes and feelings are recorded. People are treated with respect and their privacy is maintained. There is a clear audit trail of medications within the home. EVIDENCE: The homes AQAA states that: ‘all residents have detailed, up to date, clear individual care plans to support staff to meet residents needs. These are reviewed on a monthly basis, or more frequently as residents’ needs change.’ ‘Residents are supported to maintain independence.’ The home considers that it has made improvement in the past twelve months by involving people who live in the home in meetings and promoting person centred practices. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 11 When we examined care plans we found that they were well written and gave clear directions on how needs should be met. The plans lead from the individuals’ assessment of need. The format of the plans makes sure that all the required information is recorded. This enables staff to complete the documentation consistently. The plans focus on a person’s existing skills and abilities, as well as what they would like assistance with. We found that plans were regularly reviewed each month or more often if needed. Any changes to care needs were documented with reasons. Each plan had a recent photograph of the person and indicated by which name they wished to be called. Information on an individuals health and medication needs was recorded. Instructions on how to give care were sensitively written and included prompts for staff when assisting a person. For example one plan had details of what parts of themselves the individual was able to wash. Staff had instructions to supervise and remind the individual what they were doing. Communication needs were also covered. One person’s plan indicated that they ‘responded to touch as well as verbal communication.’ Each plan showed when a visit had been made by a health professional, such as the district nurse visiting to monitor someone’s blood. Care plans were noted to be person centred and were written from their perspective. An example of this was an individual’s wish for end of life care: ‘[they] would like to take painkillers in case [they are] suffering from pain or critical illnesses and ‘call the priest on the event of death.’ Each plan had details on the person’s end of life wishes and whether they wished to be cremated or buried. There was also good detail on what routine an individual liked at night. For example has ‘Horlicks with two biscuits.’ Medications were noted to be handled and administered safely. One individual has a self medication risk assessment in place for when they went away for the weekend. Staff spoken with said that they try not to give medications during mealtimes, to make sure that there are sufficient staff to assist. People that live in the home were seen to be well dressed and clean. We saw that care had been taken to make sure that people were in co-ordinating clothes of their choice. Their nails were clean and individual’s hair was groomed. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 12 We spoke with the person in charge of the laundry. She was able to tell us that some people preferred their clothes to be hung up in their wardrobe, whereas others liked their clean clothes to be left on their beds. She also told us that one person’s relative washes some of the delicate clothing. We spoke with one individual’s relative who told us that ‘[the person] benefited from being able to maintain [their] routine.’ Each persons plan had information on their chosen religion or spiritual beliefs and whether they wished to practice it or not. We found that daily records detailed what care had been given and how need had been met. For example: ‘requested water at 4am.’ We were able to verify when a person had received personal care and what health professionals had visited them. People who live in the home sign the care plan to indicate that they agree with it and this forms the basis of the contract of care. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are treated as individuals and they are able to make positive choices in what they do. Mealtimes are a sociable occasion and allow the people that live in the home an opportunity to keep their independent living skills. Family and friends are welcomed to the home and activities include socialising with the wider community. EVIDENCE: The home states in their AQAA that ‘Queen Elizabeth house puts a lot of emphasis on encouraging residents to maintain contact with family and friends, to keep active and take control of their day to day lives.’ The manager reported that improvements have been made in serving of breakfast. People can now select from a buffet in the mornings and staff are available to assist them if needed. The manager said that they would soon be serving morning coffee and afternoon tea on trays. This will enable individuals to serve themselves and chose how they would like their drinks. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 14 When we looked at care plans we noted that there was good detail on a person dietary likes and dislikes: ‘doesn’t like gravy and likes just plain vegetables.’ Also recorded was what assistance a person needed to eat, such as ‘[they] need assistance to cut up [their] food. Sometimes [they] eat with [their] hands but [they are] able to use cutlery. We observed the lunchtime meal. We noted that the people that live in the home are encouraged to sit at a table to eat their meal. Vegetables were provided in separate dishes in order that a person could help themselves to what they wanted. Each person was offered a choice of what to eat both for the main course and the pudding. There was a choice of cold drinks available and condiments were on the tables. One person was enjoying a glass of wine with their meal. Meals were presented attractively and people spoken with said they enjoyed the food. The meal was unhurried and sociable. Members of staff sat by an individual if they needed assistance to eat. Some were having a meal with the people that live in the home and were seen to be chatting with individuals about what they been doing. The manager also told us that they plan to provide a microwave and toaster for people to make their own snacks if they chose. Peoples’ interests and hobbies are noted on admission to the home. One person was seen in the garden reading their newspaper. They told us that it gets delivered weekly. Another individual was reading a book of their choice, which was confirmed when we spoke with them. The manager told us that there are plans to attend a sister home’s garden party in the summer and outings are arranged to places of interest. The home benefits from having two activities co-ordinators who are responsible for arranging meaningful activities both inside and outside the home. Examples of activities organised in the past twelve months have included; tea Dances, Musical Bingo, presentation parties, Garden Parties and entertainers. The home has a library. Bromley library routinely change the books. We saw that there were large print books available. The home has started to gather more detailed information on each person’s life history. We found one individual had a large file that contained a detailed life story. There were many photographs of the person throughout their life and significant others. Pages had been written on their memories of where they had been and lived, including type of housing, addresses and any pets they might have had. The home states in its AQAA that this is the aim for all people, but they are able to chose not to disclose any information about their life. We found on one plan that we inspected that the individual had declined to discuss their life history and this had been noted. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 15 On each plan that we looked at there were individualised risk assessments. These covered activities such as going out alone, going on holiday and self medicating. We were able to speak with relatives who were visiting the home and they praised the home and its staff. They confirmed that they are made to feel welcome and are offered refreshments. The home makes sure that people are able to keep in contact with their families and friends. One person said that they phone their relative in Australia every week. The AQAA indicates that all of the people who live in the home have had contact with friends or family. The manager confirmed that individuals are registered to vote if they want to. She said that at present the home is not accommodating any couples, but two of the people enjoy each others company and staff make sure that they have privacy if they want it. One person we spoke with was complimentary about being able to do what they wanted to do, when they wanted to do something. Queen Elizabeth House plans to build on the service offered in the next twelve months by displaying sample menus in the home to make sure people can access information easily. This might be done in pictorial format. A weekly ‘shop’ has been created, that lets people purchase small items such as stamps, crisps and chocolates. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual can be confident that any concerns or complaints they may have will be acted upon if necessary. People are protected from harm by Safeguarding procedures within the home and the ability of staff to take the correct actions. EVIDENCE: Queen Elizabeth house has said in its AQAA that their ‘complaints procedure is displayed in the home’ and ‘all complaints/comments are listened to and acted on promptly and without delay.’ We saw that the complaint’s procedure was displayed in the entrance hall. One relative spoken with said that the person had been in Queen Elizabeth House for three years and they were happy with the care given. This was confirmed by the person who lived there. The person said that they were ‘very happy.’ Another person said they had lived in the home for about three years and were pleased with the care given. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 17 One person said that if they had any concerns they would go to a member of staff or the manager to sort it out, but that they had not had any concerns recently. The home states in its AQAA that they have no received any concerns or complaints in the last twelve months. There has been one Safeguarding Adults referral that was dealt with appropriately. The Care Quality Commission has not received any concerns or complaints about the service. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Queen Elizabeth House offers a homely environment for people to live in. Care is taken to make sure that individuals are able to chose the décor and bring personal items into the home. There is a safe accessible garden for people to use and sufficient communal space. The home is kept clean and tidy. EVIDENCE: Evidence from the AQAA indicates that there is ongoing redecoration and maintenance of the home. Individuals can personalise their rooms and are able to access a pleasant garden. One person who lives in the home was happy to show us around the communal areas. The home has a large communal lounge where the furniture is Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 19 arranged in small groups. This allows individuals to choose where to sit and who they want to speak to. People that live in the home told us that most people have favourite places to sit and this is respected. We saw that people had brought in personal items from home for their rooms, such as photographs and ornaments. The garden is accessible and there are benches and chairs for people to sit on. We spoke with one person and their relative who said that they enjoyed sitting in the garden when the weather was good, as there were plants and birds to see. Other people who live in the home were seen sitting enjoying the sunshine and having a chat. One of the people had their newspaper with them. Throughout the site visit we noticed that individuals were able to move freely around the home. One person greeted us when we arrived for the inspection. The home was clean and tidy and redecoration had been done to a high standard. People spoken with said that they had been involved in choosing colour schemes. This was also confirmed by a relative. The manager informed us that they plan to upgrade one bathroom to create a wet room, to allow people to make choices about whether to have a bath or shower. All corridors, staircases, the reception office and four bedrooms have been redecorated. There is an ongoing programme of decoration and refurbishment. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 , 29 and 30 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that their needs are met by the numbers and skill mix of staff, that they are in safe hands and staff are trained and competent to do their jobs. The recruitment process makes sure that individuals are protected from harm. EVIDENCE: The AQAA states that ‘Queen Elizabeth House recruits only high calibre staff. All applicants are vetted thoroughly, to protect the interests of the residents. There is an ongoing programme of training and development for all staff. All staff receive induction, regular supervision and annual appraisals.’ During the site visit interviews for new members of staff were taking place. We saw people that live in the home speak with these people as they were waiting to be interviewed. Individuals were asking what job a person was applying for and telling them about the home. We also noted that as part of the interview process all candidates were taken to meet some people that live in the home. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 21 We looked at a selection of staff files and found that they included all the required information. Each file had an application form, proof of identity and permissions to work in the United Kingdom. People were asked if they had any previous cautions or convictions and Criminal Records Bureau checks had been carried out. There was information on a person’s full employment history and any gaps were explored. We were able to evidence that a good recruitment process was followed as there were interview notes on the files. Induction training is given to all new members of staff according to Care Skills guidance. Each employee had records of supervision and training undertaken. The most recent training was on Mental Capacity. The AQAA stated that there is ongoing training in NVQ levels 2, 3 and 4. Activities co-ordinators have attended training in chair music and movement exercises. The AQAA says that: ‘All staff have undertaken and have refresher sessions on the statutory training such as Moving and Handling, First Aid, Food Hygiene and infection control.’ Other training that has been given in the past twelve months includes: Leadership, Supervision of Staff, Nutrition in Care Homes and Report Writing. The manager reported that staff are due to be registered for Safeguarding distance learning training. The staff will be given training on managing meetings to enable them to develop their skills further. Staff we spoke with confirmed that they had received statutory training and training in other areas such as life story compilations and nutrition. One member of staff had recently completed their NVQ level 2 and was due to commence level 3. Staff told us that they were paid to attend training. There were sufficient staff on duty and people that lived in the home told us that staff were always available to assist them. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well run with an ethos of empowerment and respect. Peoples views are listened to an acted upon. Health and safety within the home is promoted and protected. EVIDENCE: The manager told us that she had worked at the home for many years. The members of staff spoken with during the site visit had worked at the home for an average of about two years or more. The staff team is stable and the AQAA shows that no agency staff have been used in the past twelve months. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 23 The manager has completed her registered manager’s award and is experienced in working in the care centre. The AQAA was completed in detail and gave a clear indication of how the home is currently operating and plans for further improvement. All the staff were polite and helpful during our site visit. They were able to locate files or information when ask. People living in the home were seen to approach the manager with any queries they might have. Relatives spoken with said that the manager and staff were good and they were made aware of any issues affecting a person. Staff records contained supervision notes and we saw that sessions were planned two monthly. The AQAA states that there is an annual quality assurance system in place and ‘resident centred practices are promoted within the ethos of the home with the involvement of all parties.’ ‘Open communication is encouraged between all parties and suggestions/comments are welcomed.’ Discussions with the manager confirmed that we can be confident that the home is run in the best interests of the people that live there, as the ethos is one of it being a ‘persons home’, first and foremost. The manager was a positive role model for staff and was able to demonstrate that the person is the focus of the care given, through our discussions and observations at the site visit. There was evidence on individuals’ plans about who managed their finances, this was usually a relative. The home does not manage anyone’s finances. No issues with health and safety were identified at the time of the site visit. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 24 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 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 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 3 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 3 X 4 X 4 Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 25 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. 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 Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 26 Care Quality Commission National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Queen Elizabeth House DS0000006962.V376084.R01.S.doc Version 5.2 Page 27 - 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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