Care Home: Queens Park Court

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What the care home does well The manager provides people with good information and displays copies of it on the notice boards around the home. People visiting their relatives and friends are made to feel welcome and the home offers good home cooked food.The home`s staff provides people with good support and they have a good understanding of peoples` needs. There is a good range of activities that is being developed further by the new training/activities co-ordinator to ensure that people have plenty to do. Queens Park Court has plenty of space where people can go to spend some private time with their relatives and friends and it provides a well maintained, clean and safe environment for people to live in. There are good recruitment procedures and staff are well trained and the medication practice is good and includes regular checks on staff competence to ensure that medication is administered safely to people living in the home. The home has a good system for safeguarding the money that they hold for people using the service. What has improved since the last inspection? There has been an improvement in the care planning and risk assessment process since the last inspection and the care plans now include more information on the level of assistance that people require. The healthcare records now contain more detailed information about visits to health care professionals and they include any actions that need to be followed up. The staffing levels have been increased to ensure that there are more staff on duty at quiet times such as in the early afternoon and between 8pm-9pm in the evenings. Staff training has improved and has included service specific issues such as diabetes and Parkinson`s disease in addition to safeguarding and dementia. What the care home could do better: Some of the care plans need to be developed further to ensure that people get the right level of support, particularly in the area of bathing, where some of the care plans are not so detailed. There should be a staff file for every person working at the home and this must be made available for us to inspect and each staff file should contain evidence that the staff member is physically and mentally fit to work there. CARE HOMES FOR OLDER PEOPLE Queens Park Court Goldington Cresent Billericay Essex CM12 0XR Lead Inspector Pauline Marshall Key Unannounced Inspection 08:55 24 and 25th March 2009 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 Queens Park Court DS0000067527.V374717.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. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queens Park Court Address Goldington Cresent Billericay Essex CM12 0XR 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) 01277 630060 01277 634660 Rushcliffe Care Limited Mrs Carole Ann Stockbridge Care Home 40 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (7), Old age, not falling within any other category (40) Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Personal care to be provided to no more than forty (40) Older People over the age of 65 years (OP). Personal care to be provided to no more than twenty (20) service users with Dementia (DE). Personal care to be provided to no more than seven (7) service users with a Mental Disorder who were accommodated at the home at the time of registration. No new service users with a Mental Disorder diagnosis to be admitted to the home. 1st October 2008 Date of last inspection Brief Description of the Service: Queens Park Court is a large detached purpose built care home providing care and accommodation for 40 older people, some of whom may be diagnosed as having dementia. The home is situated in a residential area of Billericay and the town centre is a short distance away. Rushcliffe Care Ltd owns the home and the registered manager is Carole Stockbridge. Accommodation consists of 40 single bedrooms each with en-suite facilities. People at the home are accommodated in four separate bungalows, each with its own kitchen and living/dining area. There are a number of secure garden areas around the home. There is a large central dining/lounge available for community activities and this can also be used as an alternative dining facility. The central communal area is shared with the people living in the attached Sheltered Housing complex. The main kitchen serves meals to both people living in the home and to the tenants living in the sheltered housing; it’s main function is meal preparation for the people living in the home There are adequate car parking spaces at the front of the home for visitors. The manager provides people interested in using the service with a copy of the home’s Statement of Purpose and Resident’s Guide. A copy of the homes last inspection report is displayed on the notice board. Weekly fees range between £478.09 and £715.00 per week and there are additional charges for chiropody, hairdressing, toiletries and newspapers. Queens Park Court DS0000067527.V374717.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 stars. This means that the people who use this service experience good quality outcomes. This was an unannounced key inspection that took place over a two day period. The visit on the first day lasted for eight and a half hours and the second visit lasted for one hour. All of the key standards were inspected; we checked a random sample of policies and procedures and examined some of the records that the home is required to keep. We looked around the building and we spoke to staff, visiting relatives and the care team manager. We checked the progress of the requirements that were made at the last inspection. The manager completed her annual quality assurance assessment (AQAA) and returned it to us within the required timescale; it was detailed and informative and provided us with good information about the service. The AQAA is a self assessment document that the manager is required by law to complete; we have used the information provided in the AQAA throughout this report. We sent surveys to fifteen people using the service, six health and social care professionals and fifteen staff to obtain their views on the service the home provides. We did not receive any completed surveys from the people using the service but two of their relatives used the surveys to share their views with us. Their views were mixed but overall they said that they were happy with the care their relative received. One health and social care professional returned their completed survey and they were very complimentary about the home and made many positive comments that we have included in the body of this report. No other completed surveys were received by the due date. What the service does well: The manager provides people with good information and displays copies of it on the notice boards around the home. People visiting their relatives and friends are made to feel welcome and the home offers good home cooked food. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 6 The home’s staff provides people with good support and they have a good understanding of peoples’ needs. There is a good range of activities that is being developed further by the new training/activities co-ordinator to ensure that people have plenty to do. Queens Park Court has plenty of space where people can go to spend some private time with their relatives and friends and it provides a well maintained, clean and safe environment for people to live in. There are good recruitment procedures and staff are well trained and the medication practice is good and includes regular checks on staff competence to ensure that medication is administered safely to people living in the home. The home has a good system for safeguarding the money that they hold for people using the service. What has improved since the last inspection? What they could do better: Some of the care plans need to be developed further to ensure that people get the right level of support, particularly in the area of bathing, where some of the care plans are not so detailed. There should be a staff file for every person working at the home and this must be made available for us to inspect and each staff file should contain evidence that the staff member is physically and mentally fit to work there. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 7 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. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wanting to use the service would be able to make an informed decision regarding whether the service could meet their needs. EVIDENCE: The Statement of Purpose was detailed and informative; it described the service that the home provides and included the contact details of the registered provider. There were copies of the home’s philosophy of care, complaints, fire procedures and the most recent resident’s satisfaction survey report included in the Statement of Purpose. Each of the four care files examined included confirmation that the person living in the home had received a copy of the Statement of Purpose and Residents Guide prior to their admission. The Resident’s Guide provided people using the service with a summary of the home’s last CSCI inspection report and there were leaflets on Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 10 the notice board advising people of the contact details of ‘The Relatives & Residents Association’ who can provide people with advice about their care. Each of the four care files examined contained a detailed and thorough preadmission assessment. The manager said in her annual quality assurance assessment (AQAA) “people wishing to use the service and their relatives are invited to visit the home prior to admission” and people spoken with confirmed this. Following the pre-admission assessment a letter is sent to the individual to confirm that the home is able to meet their current needs. Four weeks after admission a full review takes place to ensure that the person is satisfied with the service; the review process includes the involvement of the person using the service, their family, a senior member of the home’s care team and a social worker if the person is funded by the social services. The care manager said that the pre-admission process for people admitted for respite stays differs slightly; the COM5 (placing authority assessments) are read and any concerns or shortfalls in information are discussed with the relevant people and a further assessment carried out if necessary. The care manager also said that all people using the service, including people that stay for respite, are assisted to complete the home’s “Getting to Know You” personal information sheet. This form asks for information about a person’s significant life events both pleasant and unpleasant, it asks about their formative years including where they grew up, where their school and college was and information about their close family, their occupation, their hobbies and interests, their likes, their dislikes and their fears. All of the care files examined included a fully completed “Getting to Know You” form, which provided staff with good information that could be used when conversing with people living in the home. Staff was observed interacting with people throughout the inspection and they appeared to have a good knowledge of individual’s personal likes and dislikes. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home receive appropriate health and personal care to meet their assessed needs. The home’s medication policy and practice will protect people from the risk of medication errors. EVIDENCE: Four care files were examined and all included a quick reference sheet, which highlighted the person’s care needs; there was more detailed instructions in the care plans to fully explain the level of assistance that people required. Staff spoken with confirmed that the quick reference sheet was very useful and that it highlighted the basic tasks alerting staff to the more detailed care plan. One of the care files examined required more information as it showed that a person needed assistance with bathing but did not provide clear instructions on how staff was to assist; the other three care files examined were very detailed about the level of assistance people required. Each of the Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 12 care files examined contained risk assessments for any identified risks and there was evidence that all of the care plans and risk assessments had been reviewed. The care files were being regularly audited by a senior manager, the last audit took place on 23/2/09 and it identified that some care plans required more information. The audit recognised that progress had been made and improvements seen and the issues that had been identified by the audit were discussed at the care team leader meeting on 25/2/09. The care team leader said that senior staff had been working through all of the care plans to ensure that they contained sufficient detailed information. People spoken with said they were happy with the care provided and that staff were kind and helpful when assisting them with all aspects of their care. One health and social care professional said in their survey “the home makes good use of available resources and they always apply regular assessments; the physical, psychological, emotional and spiritual needs of people are met at all times”. Each of the care files examined contained full details of health care appointments to GP’s and hospitals. The home has a treatment room that can be used for chiropody or dental work; one person was receiving dental treatment in the privacy of their own room. A relative of this person said when spoken with that their relative preferred to have their treatment in their bedroom and that staff would always check if this was required. The health and social care professional said in their survey “when we visit, all procedures are carried out with respect and individuals are treated with dignity and in private”. Medication is stored securely in a locked cabinet inside a locked room where the temperatures are monitored and recorded. Only senior staff administers medication and they have all had medication training; there was evidence on the staff files to confirm that their competence is regularly assessed. The registered manager carries out a medication audit weekly. A random check of the home’s medication showed that it had been correctly accounted for; there were no gaps on the MARS (medication administration sheets) and the packs contained the right number of tablets. Queens Park Court DS0000067527.V374717.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to access appropriate activities that meet their needs and they are offered a choice of healthy home cooked meals. EVIDENCE: The home has recently employed an second activities co-ordinator and there was evidence on the care files examined that a good range of activities were offered to people living in the home, including sing-a-longs, reminiscence, exercise to music, arts and crafts and bingo. The manager said in her AQAA “the local church group provides a themed activity programme for Monday mornings and a church service is held monthly, which all denominations are welcome to attend”. People spoken with said that they enjoyed the in house activities and the church services and that they were busy making Easter cards and bonnets ready for the Easter celebrations. The new activities co-ordinator said that she is enquiring about hiring a bus to enable people to take part in more outside activities. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 14 Several of the people living in the home said when spoken with that they prefer to stay in and did not want to go out but are happy sitting in the garden in summer. There were mixed views in the surveys received from the relatives of people living in the home and one said “there is not enough stimulation, I often find my relative and others asleep with the TV or radio on”, another said “my relative says there is always plenty to do”. All of the completed surveys said that the home attends to their relatives’ personal needs very well and that people are always clean and well fed. The care files examined showed that people living in the home and their relatives are involved in all aspects of their care and people spoken with confirmed that they are consulted on any issues that arise within the home. People living in the home said when spoken with that they could have visitors’ whenever they wanted; there were friends and families visiting throughout the day. Relatives spoken with said that they were always made welcome by the homes’ staff and confirmed that they were able to visit whenever they chose to. There is ample space available, in addition to people’s bedrooms, where they can meet with their visitors in private. Queens Park Court offers a four-week rolling menu with a choice of two alternatives for each meal. The cook prepares a cooked breakfast for those that prefer it and people spoken with said that they enjoyed the food especially the bacon and eggs. Each of the bungalows has a small kitchen where they can prepare snacks and drinks for people between their main meals. The main kitchen had a fully completed daily, weekly and monthly cleaning rota, it was clean and tidy and had a good food stock, all open foods in the cupboards, fridges and freezers was well wrapped and dated. People spoken with, including visitors to the home said that the food was excellent and that it was home cooked and always well presented; an observation of the mealtime confirmed this. The home has recently had a food hygiene inspection and it was awarded four stars. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 15 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People know that their concerns will be dealt with and that they will be protected from harm and abuse. EVIDENCE: The home has a clear complaints procedure that is included in their Statement of Purpose and their Residents Guide; there is a copy displayed on the notice board. The procedure was last reviewed in November 2008 and the care team leader said that it was due to be reviewed again shortly to include the new Care Quality Commission details and the level of our involvement in any complaints. The manager said in her AQAA “we maintain records of all complaints made, action taken, investigations and outcomes”, and the complaints folder confirmed this. The last complaint was made on 22/12/08 and the records showed that it had been appropriately dealt with. People living in the home and their relatives said when spoken with that they were fully aware of the homes complaints procedure and knew who to speak to if they were not happy with anything. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 16 The abuse policy provides staff with clear instructions on what they should do if they suspected abuse and the staff spoken with had a good awareness of the procedure. There were cards in a rack attached to the notice board giving details of who people could contact in the event of abuse. The training matrix showed that since the last inspection fourteen staff had attended the Protection of Vulnerable Adults from Abuse training and that there was more sessions scheduled for later in the year. The care team leader and the training co-ordinator confirmed that the organisation would be providing abuse training throughout the year so that all staff could attend and have regular updates. There were certificates on the staff files examined confirming that this training had taken place and the staff spoken with at the inspection said that they had received abuse training. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 17 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, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe, homely and comfortable environment. EVIDENCE: Queens Park Court is divided into four areas that are referred to as bungalows and it has a complex of sixty flats adjoining it. Each bungalow has a lounge, a dining area and its own kitchen where light meals, snacks and drinks can be prepared and people have their own individual bedrooms that were all nicely decorated to people’s individual tastes. People spoken with said that they were happy with their rooms and also that they enjoyed the option to use the larger lounge areas if they wanted to. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 18 The large lounge areas provide lots of seating and there is an electric organ, a piano and a dry bar where tea, coffee and soft drinks can be served during functions. There was tables and chairs in the garden and a secure area to provide people with safe outdoor space; one person said when spoken with “I enjoy sitting in the garden when its warmer and I like to sit under the umbrella and have a cup of tea”. The manager said in her AQAA “a maintenance person is employed to maintain fabric/furnishing and take necessary remedial action to fix any deficits”. The rota showed that the handyman worked three days each week at the home. The home was in a good state of repair, it was clean tidy and hygienic and people spoken with said it was always kept “nice and clean”. There was no odorous smells noticed at either of our two visits. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 19 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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are cared for by a competent, well-trained and supervised staff team, who are safely recruited. EVIDENCE: Queens Park Court operates a shift system where six staff are on duty from 7.00am to 14.15pm and five staff are on duty from 14.15pm to 21.00pm and there are three waking night staff; there are two managers in addition to this. The home also employs two members of staff as activities co-ordinators, two cooks, one catering assistant, three housekeepers and a handyman. The care team leader prepares a daily work schedule, this gives a more detailed description of where staff are deployed and it showed that adequate staff were on duty to meet the needs of the people currently living in the home. The manager said in her AQAA “dependency levels are recorded on a monthly basis and staffing levels are reviewed accordingly”. The care team leader confirmed that the rota is amended to reflect the changing dependency levels of people living in the home. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 20 There were records to show that four staff has achieved an NVQ level 3 in care and another six are working towards it. The manager said in her AQAA “sixteen staff has completed either level 2 or 3 NVQ in care”, the staff training records confirmed this. All three catering staff are currently undertaking their NVQ level 2 in Multi Skills Hospitality. Six staff files were examined and five of them included fully completed application forms, two written references, clear Criminal Records Bureau checks (CRB), training certificates and supervision records. There was no evidence on the staff files examined of staff fitness as required under Schedule 2 of the regulations; the manager must obtain this and keep a record on the staff files. The sixth staff file was not available; the care team manager said that this had not been brought over from the last home where the employee had worked. The staff files of all employees working at the home must be made available for inspection. There were training records to show that staff has attended a range of training including moving and handling, medication, health and safety, food hygiene, fire, abuse, epilepsy, record keeping and care planning and dementia. Nineteen staff are currently undertaking the National Certificate for Further Education (NCFE) level 2 certificate in dementia awareness and the programme consists of four units. The four units cover the understanding of dementia, the understanding of person-centred dementia care, understanding challenging behaviour in the context of dementia and applying a person-centred approach to dementia care. In addition to the NCFE training there are twenty staff working through the Social Care Information and Learning Service (Scils) Dementia and Confusion workbook. More than half of the staff team had attended an update of their abuse training and further sessions are scheduled for later in the year to ensure that all staff has attended. Staff spoken with said “the training has got really good recently; there is plenty of it, especially the training around dementia which is very interesting and helps in our work”. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 21 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, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People will live in a well run home that is run in their best interests. EVIDENCE: The registered manager has many years experience in working with older people with dementia and has achieved the registered managers’ award and has attended health and safety, fire, control of substances hazardous to health (COSHH) and the Protection of Vulnerable Adults (POVA) training. The registered manager is due to retire in November 2009 and the new manager is working alongside her until then; the new manager is experienced and holds Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 22 the registered managers award, she has had recent training in dementia, fire, the Mental Capacity Act (MCA) and the Deprivation of Liberty (DOL). The home holds regular meetings for staff and the people living in the home and there was records confirming that these take place regularly. Staff and people living in the home said when spoken with that they often attend meetings where the running of the home is discussed. The manager completed the homes annual quality assurance assessment (AQAA) fully and it contained all of the required information and was returned by the required date. The organisation carries out an annual survey to obtain the views of the people living in the home and of their relatives; a report is then prepared by a senior manager. The report identifies any issues where actions are necessary and the manager then prepares an action plan to address them. Copies of the report are then pinned to the notice board in the home and are discussed at staff and residents meetings. The manager should obtain the views of other people such as GP’s, social workers, community nurses and advocates ensuring that the views and opinions of all people connected to the service are included. The cash transaction records together with their corresponding cash for four of the people living in the home was checked, and were all found to be correct. All of the staff files contained evidence that regular supervision takes place and staff spoken with confirmed that they felt well supported in their work. A random sample of safety certificates was checked and all were in place and up to date. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 23 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 24 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. 1. Standard OP29 Regulation Schedule 2 Requirement The manager must ensure that all of the staff records listed in the regulations is available for inspection and that the staff files contain evidence of staff fitness. To ensure that the people living in the home are fully protected. Timescale for action 29/05/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that the manager continues the development of the care files to ensure that staff has clear instructions on the level of assistance that people require in all areas of need. It is recommended that the manager obtains the views of DS0000067527.V374717.R01.S.doc Version 5.2 Page 25 2. OP33 Queens Park Court other people such as GP’s, social workers, community nurses and advocates when undertaking quality assurance surveys to ensure that the views and opinions of all people connected to the service are included in their findings. Queens Park Court DS0000067527.V374717.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Queens Park Court DS0000067527.V374717.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. 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