Care Home: Queen Mary House

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What the care home does well What has improved since the last inspection? What the care home could do better: CARE HOMES FOR OLDER PEOPLE Queen Mary House Manor Park Road Chislehurst Kent BR7 5PY Lead Inspector Sue Meaker Key Unannounced Inspection 2:30 25 & 27 November 2008 th th 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 Queen Mary House DS0000038956.V373212.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. Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queen Mary House Address Manor Park Road Chislehurst Kent BR7 5PY 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 3112 020 8468 7200 sueandann.qmhouse@hotmail.co.uk School Mistresses and Governesses Benevolent Institution Mrs Ann Baker Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Queen Mary House DS0000038956.V373212.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 - Code PC to service users of the following gender: Female whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 36 14th November 2006 Date of last inspection Brief Description of the Service: Queen Mary House is a large, detached three storey, purpose built home. The home is situated in a quiet residential area in Chislehurst in the London Borough of Bromley. The home is close to open woodland and Chislehurst common, and within walking distance of local shops and public transport. The home is administered by the Schoolmistresses and Governesses Benevolent Institution, a charity founded in 1843 and incorporated by Royal Charter, the home provides spacious accommodation in pleasant surroundings, for retired ladies from these and comparable professions. The home is surrounded by well maintained gardens which are easily accessible to the service users. Bedrooms are on two floors accessed by a passenger lift, benefiting from central heating, the temperature of which can be individually controlled by the service users. There are hand and grab rails on the stairs, in passageways, toilets, showers and bathrooms. Specialised bathing and toilet equipment and moving aids are readily available; all toilets, showers, bathrooms and bedrooms can be accessed from the outside in case of an emergency. There is easy access to a telephone and the majority of service users have their own telephone in their rooms. There is an emergency call system in all areas of the home used by the service users; and members of staff are on hand at all times to assist the service users as required. Queen Mary House DS0000038956.V373212.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 2 star. This means that the people who use this service experience good quality outcomes. This service had an Annual Service Review completed on the 2nd January 2008. The Annual Service Review did not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection. This was an unannounced statutory key inspection; two visits were made to the service one on the 25/11/2008 the registered manager was not at the home, the duration of this visit was an hour, the second visit was made on the 27/11/2008 with the registered manager present throughout the inspection which took five hours. The Annual Quality Assurance Assessment document was competently completed by the registered manager and gave very good information about the service. Questionnaires were sent out prior to the inspection and the following were returned to us:• • • • 9 8 2 3 from from from from people who use the service. relatives, carers and advocates. staff working in the home healthcare professional who visit the home on a regular basis. The inspection consisted of a tour of the home chatting to the residents and to visitors, and speaking to the staff on duty; during this tour the opticians arrived and there was a opportunity to speak to them about the home. Looked at information about the people who use the service and how well their needs were being met. Looked at records appertaining to staff, rotas, training, health and safety, the menu and activity programme and the business plan for the organisation. Checked the staff had the knowledge, skills and training to met the needs of the people in their care. Looked in detail, at three care plans and three personnel files. Looked around the building making sure it was clean, comfortable and safe for residents, visitors and staff. Checked what improvements had been made since the last key inspection. Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 6 What the service does well: This home provides a good quality service to its residents; providing a safe and homely environment, the home is spacious, comfortable, well decorated and furnished to a high standard creating a home from home atmosphere clearly appreciated by the residents and relatives. The home benefits from effective, efficient and caring management team and a truly committed staff team; who receive good training enabling them to have the skills and competency to meet the assessed personal, health and social care needs of the residents in their care. The home has a good activities programme incorporating social events, external entertainment and outings provided by an activities co-ordinator with enthusiastic support and encouragement from staff, residents and their relatives. Queen Mary House provides a high standard of care to its residents in a congenial atmosphere. The residents appear to happy and content in their environment and the staff also are part of creating this atmosphere within the home. The home is to be commended on its high standard of service provision achieved by competent management and a caring and committed staff team. The following comments were made on the questionnaires received:• • • • • • I moved here and have been very satisfied, the food is of a high standard and rarely disappoints. I received personal recommendations from seven friends. Very good atmosphere, food is of a high standard. The rooms are well proportioned, light with a lovely outlook. The staff are always very helpful and caring. Excellent care, food and cleanliness. Beautiful gardens and surroundings; very friendly atmosphere and very welcoming. I feel the home caters for the ladies in a very caring manner; I do not think it could improve on the care given. One of the healthcare professionals has stated the following:• Queen Mary House is a the rest home I visit, staff are always helpful and polite and pass on any messages if needed when I phone. The staff seem to stay here for a long time – great for residents. The place is spotlessly clean and the residents are well cared for and seem happy. The surroundings are beautiful, food looks delicious and healthy. This is a rest home I visit and recommend it to others looking for a home. Residents are spoiled on their birthdays and Christmas and relatives are made welcome at any time. • • Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? The service provided by Queen Mary House to it’s residents have improved in the following areas:• • • Care plans and risk assessments have improved significantly and are now more person centred and personalised to the individual. New height adjustable beds are to be purchased for each resident; currently the home has beds on trial with a view to purchase. The registered manager has contacted another home locally with a view to liaising with this home in the event of a disaster for example evacuation in case of fire; and also visiting each others homes for social events. A new fitted kitchen on the ground floor providing for the service of meals to those who wish to eat in their own rooms. Bedrooms are being made into en-suites, this is an ongoing project until all bedrooms in the house have their own facilities. A wet room has been installed with a shower chair for independent use. There is a new assisted bathroom on the second floor. A newsletter has been introduced and this will be published four times a year and will include questionnaires relating to care and catering alternately. The Registered Manager has purchased resources to enable induction and mandatory training to be done in house. • • • • • • What they could do better: The Registered Manager is looking to implement the following changes to improve the lives of the people who live in the home:• • • • Residents meetings/suggestion box/quality of life questionnaire, talk and listen to them. Changes with menu More activities, tape Songs of Praise, which is on whilst residents are having supper, in order that residents can watch following supper in the main lounge. Review policies and procedures, training of staff, encourage clergy in for communion services or to give to individuals in their room, provide disability aids. A new assisted bath to be installed, making three in total, in order to deal with the increase in ladies who require assisted baths following assessments. DS0000038956.V373212.R01.S.doc Version 5.2 Page 8 • Queen Mary House • • New electric, height adjustable beds for all rooms in order to assist with manual handling. To look at organising external outings and increasing the hours of activities offered. The registered manager and her committed staff team are able to maintain high standards of care for residents, listening to suggestions and ensuring they are involved with all aspects of their care. This should hopefully ensure that the home continues its good record of not receiving any complaints. Continued training of staff on the protection of our ladies. 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 summary of this inspection report can be made available in other formats on request. Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 9 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 Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families receive information about the home, so they are able to make an informed decision as to whether their assessed personal, health and social care needs can be met. Prospective residents have their personal, health and social care needs assessed by a competent member of the homes’ senior staff ensuring that the services provided can met. All residents have a contract giving the terms and conditions of their residency. Prospective residents and their families are encouraged to visit the home to ascertain its suitability to meet their specific assessed care needs. Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 11 EVIDENCE: Residents and their relatives are given detailed information relating to the home and the services offered, in the form of a brochure detailing the homes’ Statement of Purpose that includes the aims and objectives of the home, the services provided, the complaints procedure and the relevant qualifications and experience of the provider, manager and staff. The home also has guidance notes for new residents and this is given to all prospective and new residents it gives details of how the home is run, who is the head of home, what sort of care is provided, about the catering and times of meals and where menus are displayed , the fees, what to do in the event of a fire, about the garden, info about having relatives and friends to stay; the hairdresser, holidays, inspection reports, the library, personal mail, newspapers, the administration office, security precautions, telephones, the visitors book and there is also a copy of the complaints policy and procedure. The Home Manager has recently introduced a quarterly newsletter for the home available to prospective residents, the people who live in the home and their relatives and friends, this has been well received and many of the residents spoken to thought it a really good idea. A number of questionnaires were received from the people who use the service and a number from relatives and friends of residents, all of which were complimentary praising the high standards of care, the staff team, facilities, bedrooms and the general environment of the home. One relative stated that there was “always good communication between staff and ourselves; personal requirements and wishes are met at all times; Any problems are communicated to us, phone massages from us are always given to our relative immediately”. It was evident from reading the questionnaires that the people who use the service and their relatives were given detailed information about the homes’ ethos, the facilities available, accommodation, food and medical care and that when they visited and were always made welcome. One relative stated that “there has always been time to discuss decision making issues, face to face with management on as many occasions as necessary; there is always time for the individual resident, frien and relative”. Questionnaires received and residents spoken to confirmed that they had received a contract from the organisation detailing their terms and conditions of residency and that the contract was clear and easy to understand, a copy of the contract is given to the resident and one is kept on their personal file. One of the people who use the service stated that “I have read and signed my contract and had a signed copy by the director in four days, the document was clear and understandable. On checking a number of personal files there was evidence to show that an assessment of health, personal and social care needs had been undertaken by a qualified member of staff. Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 12 The pre- admission assessment document has been reviewed and revised since the last key inspection, it is now more person centred and gives specific information as to how the person who uses the service expects to be looked after, that their wishes and preferences are compiled with and their privacy and dignity is respected at all times. It was evident from looking at the assessment documentation that the home was able to meet the needs of the resident; where specific medical needs were identified the relevant health professionals had been contacted to provide an individual service such as the tissue viability nurse, the district nurse and physiotherapist. It was also evident that the home could provide the services of a podiatrist, dentist and optician on request. The optician was in the home of the day of the site visit and was very complimentary about the home stating that they were provided with a private room to undertake eye tests and the fitting of new glasses; they also stated that the staff were extremely helpful and they felt the residents were very well cared for and looked happy and that the home had a friendly and homely atmosphere. One of the residents stated that “the manager and care staff listen and we work together on my wishes and needs: there are always staff around to talk to and to help”. A friend of a resident in the home stated that “my friend has only been a resident for a short time but her needs are met in every way and she is happy and is already looking better in health”. . Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans inspected reflected the personal, health and social care needs of the residents; they incorporated information from the resident, their family and healthcare professionals, enabling care staff to provide care to their wishes and preferences, thereby respecting their right to choice, dignity and privacy. EVIDENCE: A number of care plans were looked at during the inspection it was noted that the information was pertinent to the care needs of the individual, the care plan covered the activities of daily living. The care plan is formulated from the preadmission assessment and reviewed and amended on a regular basis; the Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 14 home manager has reviewed the care plan and risk assessment documentation to make sure it is person centred and more specific to the individual’s assessed personal health and social care needs. From speaking to the residents and looking at the questionnaires received it was evident that the staff understood and had the skills to care for them and that the residents and their relatives were confident that their health, personal and social care needs were met. One of the residents ( who self – medicates) said that she had asked for her medication to be given to her daily; this was very carefully organised and stored and her photograph put with her medication; and saw her new doctor just after arriving at the home. Another resident ‘s family stated that the care staff are very pleasant, efficient ladies who work knowledgeably and also anticipate needs as they arise; they show respect in turn I have only noticed excellent work done by the care staff. Another relative stated that all the staff I meet are fantastic; they come over as being kind, approachable and enjoy what they do; they provide a calm, caring relaxed atmosphere; and I have absolute faith that my relative is cared for; everything seems to run with calm efficiency. Residents and relatives were also appreciative of the additional medical services that the home was able to access, this was usually done through the GP, and this was evidenced from the recording, by the staff, on the daily evaluation sheets in the individual care plans. One of the healthcare professionals who visits the home on a regular basis stated that she and her colleagues have a good relationship with the management and staff at the home who are always keen to assist in any way to improve the residents healthcare: she also said that the service provided ensures that residents are encouraged to express their preferences, the staff at the home do their best to consider and consult the residents at all times with all aspects of their individual care needs. The medication documentation was checked during the visit and complied with the homes’ policy and procedure, the guidelines from the Royal Pharmaceutical Society and the National Minimum Care Standards with the standard. Medication is dispensed from the blister pack and recorded on the individual medication administration record. Photographs are now individualised to the MARS sheet for each resident, and the medication file is now sectioned for each resident. Medication is stored safely and securely; only trained staff administer the medication and staff have recently received training in the Safe Administration of Medication as documented in the staff files. It was evident from observing the interaction between the residents and staff that they are treated respectfully and are assisted in a sensitive manner, the staff appeared to have a good rapport with them and the atmosphere in the home reflected this; residents said that the staff were helpful and caring, approachable, friendly, available and committed to meeting the care needs of their residents. Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 15 Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home endeavours to provide appropriate activities to the residents supporting and encouraging them to maintain their chosen lifestyle in a residential care home environment. The residents are provided with a nutritious and healthy menu ensuring that they maintain a healthy diet. EVIDENCE: The management and staff of the home offer a variety of activities, entertainment and outings to their residents on a regular basis. The home has a part time activities co-ordinator and during the site visit she had opened the shop for the residents; enabling them to buy snacks, biscuits, crisps and toiletries. She had also opened a Christmas shop in a spare room Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 17 in the home where residents could purchase Christmas cards, wrapping paper, small gifts. There is also a library and book club for the ladies; a clothing party had been arranged, as had a pantomime; and Christmas shopping trips and a Christmas party for relatives and friends. The home has a regular church service and some of the ladies attend the local church; carol services had been arranged in the home over the Christmas period. The home manager had accessed the Reminiscence and Communication Service who have provided information relating to appropriate activities for the residents. The activities co-ordinator arranges many activities throughout the year including gentle exercise, quizzes, board games, arts and crafts and indoor bowling. One resident said that there are many activities are arranged and at present she usually attends when entertainers come in the afternoons; and always attends the church service. A relative stated that the residents are encouraged to join in activities but are never forced into taking part if they choose. A friend of a resident stated that her friend likes her room with all her lovely thins which are appreciated by the staff who help her; she likes to walk in the garden and takes part in some of the activities on offer, such as quizzes, the shop, visiting entertainers and speakers. People who use the service confirmed that their relatives and friends are encouraged to visit the home at times suited to them and that they are invited to social events and asked if they would like to participate in the organising activities and social events. The home encourages local churches, local schools and volunteer groups to visit the home therefore maintaining contact with the local community. The home has contract caterers to provide meals from the homes’ kitchen; the contract is reviewed annually and the residents and their relatives are invited to comment about the standard of food provided; staff from the contract caterers provide a waitress service at mealtimes and the residents are consult and asked for their views about any menu changes they would like implemented. Lunch was observed, the atmosphere in the dining room was calm and dignified, residents sat at tables for four people that were set with tablecloths, serviettes and condiments. Residents had a choice of two main meals, desserts and beverages, alternative choices were provided for vegetarians and special diets and for residents who did not like the main meals offered. The residents in the main dining room were served by staff members and were able to eat unaided. Some residents preferred to have their meals in their rooms, they were assisted by staff in a sensitive and courteous manner. Residents spoken to said how much they enjoyed the meals and also the social time with other residents in the dining room. The kitchen was given a five star gold clean food award in May 2008, by the London Borough of Bromley’s environmental health officer. Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to feel safe and protected in the home due to the homes’ policies and procedures and staff training relating to complaints and the Protection of Vulnerable Adults EVIDENCE: The home has a robust complaints policy and procedure that is readily available in the homes’ Statement of Purpose and Service Users Guide; the complaints procedure is also displayed in the foyer of the home. Residents and their relatives confirmed that they knew how to make a complaint if the need arose. They stated that the management and staff of the how were approachable, friendly and helpful and this gave them the confidence to raise any concerns that they might have concerning their care. Residents said that the home manager dealt quickly and effectively with any concerns they raised. From the training files and from speaking to staff it was evident they understood the importance of the Protection of Vulnerable Adults, that they were aware of all forms of abuse and that they knew who to report allegations of abuse to and that they were aware of the homes’ “whistle-blowing” policy Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 19 and procedure. The home is governed by the guidelines produced by the London Borough of Bromley relating to the Protection of Vulnerable Adults; management and staff had received training from the local authority about this issue and in house training had also been provided through training videos and workbooks. The home has a copy of the Bromley Guidelines and the Department of Health guidance “No Secrets”. The home manager is aware of the legislation relating to the POVA register. The questionnaires completed by residents in conjunction with their relatives evidenced that they are very satisfied with the care services provided by the home and that they feel very safe and supported by the home that has their protection and safety as a priority. Staff understood the importance of promoting the individuals’ rights, which is why the home has, in place, systems that ensure the resident’s rights are respected. Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, clean and hygienic, well maintained, well equipped and comfortable home, making sure that the layout and design of the home encourages and supports resident’s independence. EVIDENCE: The home is decorated and furnished to a high standard providing residents with pleasant, homely surroundings in which to live comfortably. The home was clean, tidy and free from any odours and it was evident that the team of domestic staff maintain the home to a high standard. Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 21 All residents have single rooms, some of which have en-suite facilities, decorated and furnished to a high standard. It was noted, during a tour of the home, that all bedrooms were personalised reflecting the residents’ hobbies and interests; some of the residents also had their own pieces of furniture, ornaments, pictures and photograghs The communal areas of the home, the lounges, dining rooms, conservatory and the library are well decorated and comfortably furnished retaining a home from home feel for the residents. One residents’ friend stated that there were attractive surroundings throughout the home – plants, fish, birds – good to have other living things and the beautiful garden is a joy. A resident of the home stated that “this is a most attractive, clean home in all the areas”. The home has an extensive garden, accessible to all residents, the garden is well used in the spring and summer months when at its best, very attractive and well- maintained with plenty of seating areas one of the residents said that the garden was spacious and lovely. The home has an ongoing programme of refurbishment and re-decoration and a committed maintenance person to carry out the work. The ground flooor has a new fitted kitchen, and residents who wish to have meals in their rooms are served from her; there is a new wet room with a shower chair, a new assisted bathroom on the second floor and a refurbished assisted bathroom on the ground floor. There is the on going programme of changing, in time, all the bedrooms into ensuites, some have been completed since the last inspection. There are personal laundry facilities on the ground floor and a second one on the first floor both in good order, the bulk of the laundry is done under contract away from the home. The home was having new boilers and central heating system being commissioned; this was in the process of being completed with the minimum amount of disruption to the residents and the services provided to the residents. The home manager is in the process of changing all the beds in the home – some new adjustable beds were being tried out; this was successful and the home is now purchasing new beds for all the residents. The home ensures the health and safety of the residents, ramps are provided for wheelchair users and the corridors, communal areas and the gardens have handrails. The home has a well-maintained passenger lift giving residents access to all areas of the home. Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home ensures that all staff are trained in order to have the skills and competency necessary to meet the personal, health and social care needs of the residents in their care; this outcome is achieved by implementing thorough recruitment, selection and training policies and procedures. EVIDENCE: Rotas seen showed that the number and skill mix of staff are appropriate to the assessed personal, health and social care needs of the residents Staffing levels have been increased recently in order to meet the increased in the home. The home has robust recruitment and selection procedures; each member of staff has their own personnel file containing the information specified in Schedule 2 of the National Minimum Standards; therefore complying with regulation 19 of the Care Standards 2000. New staff only commence employment once suitable references, CRB and POVA checks have taken place. The home has a comprehensive training programme in place and a designated budget to maintain a high level of training. The home is a member of the Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 23 Bromley Training Consortium and is now able to access training courses relating to moving and handling, risk assessment, loss and bereavement, dementia introduction, dementia intermediate, report writing, basic assessment and safe administration of medication. The home manager has also accessed external training in infection control (from NHS), customer care (working with relatives and understanding older people),equality and diversity and depression in older people. Induction training for new employees complies with Skill Council by way of BVS – common induction standards with a workbook to complete within six weeks prior to undertaking NVQ 2 Most of the staff have achieved NVQ 2 and 3, and a one member of staff is to undertake her Registered Managers Award. The up take of funded NVQ training in this home complies with the National Minimum Standards. Five members of staff hold a valid first aid certificate. It was evident from the training files and from speaking to staff on duty that they had regular updates for their mandatory training in moving and handling, health and safety, fire and food hygiene. The management of the home is:• Encouraging staff to undertake more training. • Giving a better remuneration package, which has seen the introduction of a second bonus together with increased holiday for long service. • Ensuring we keep our excellent staff through the package offered to them. • Making sure they feel valued. Having listened to comments regarding difficulties of making low, heavy beds we are in the processing of looking at the home supplying all beds which would be height adjustable and easy to manoever. • Meeting their diverse needs thereby implementing the equal opportunities policy and procedure and offering training in managing equality and diversity in the workplace. From the staff questionnaires received the following comments were made:• I could not start work until I received my CRB and my two references. • I had to do all shifts as part of induction shadowing the permanent staff. Also we always work in pairs. • I have been given training relevant to my role. • The training courses offerred are purchased in advance from Bromley Council; we book our courses in advance and there is no limit – carers can attend as many as they wish however manual handling is mandatory twice a year. Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 24 Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is competent, qualified and experienced, and manages the home to a high standard, she operates an open door policy for the people who use the service, their relatives and her staff. The home has effective and efficient management and administration systems in place to ensure the best interests and health and safety of the residents and staff; management make sure that the administration systems ensure the home is financially viable. The home is continuing to develop their quality assurance system, enabling them to monitor the quality of service provision Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 26 EVIDENCE: The home has a competent and experienced manager who is supported by a committed staff team. The manager understands the philosophy of the home and is able to meet its aims and objectives as set out in the Statement of Purpose. From questionnaires received and from speaking to residents it was evident that they felt that the management and staff at the home were approachable, friendly, helpful, willing to listen, compassionate and sensitive to individual needs. They also said that any concerns they raised were dealt with in a sensitive and compassionate manner and resolved quickly with the minimum amount of fuss and that there were always members of management around and accessible. The home has a ladies committee who visit the home on behalf of the Schoolmistresses and Governesses Benevolent Institution and this committee produces an annual quality of life questionnaire. The residents and their relatives are asked to comment on the provision of care, the accommodation and the meals, their anonymity being preserved. Issues raised by the residents were addressed and resolved by the management of the home and the home maintained records appertaining to these meetings held with staff and residents and relatives. The Home has a supervision and appraisal system in place and this is now fully implemented each member of staff has their own record of supervision and a personal development plan identifying training needs. The homes’ business plan was seen and it was evident from this document that the home is in good financial shape and is able to meet all current financial commitments. The home has robust policies and procedures in place relating to health and safety of residents and staff, the pre-inspection questionnaire showed that regular safety checks were undertaken and recorded in accordance with current health and safety legislation. Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 27 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 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 28 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 Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Queen Mary House DS0000038956.V373212.R01.S.doc Version 5.2 Page 30 - 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. 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