Care Home: Queenswood Care Home

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What the care home does well What has improved since the last inspection? What the care home could do better: Staff should be aware of information gathered about anyone new moving into the home. Staff should always observe people taking their medication. One person said, "I am not able to medicate myself, I am given my tablets in the morning". Some shortfalls were highlighted concerning the menu and quality of the meat. One person commented when asked what she thought of the food, "casserole, casserole, casserole". Another person said, "We do have quite a lot of casseroles but they are different, they have to cater for a lot of us. It would be nice to have a lamb chop sometimes, but perhaps they haven`t got the space to do it" The current staffing levels and deployment of staff should be reviewed to make sure people have their needs met in good time. One person said at 10.00am "You try and find staff now, you won`t find one. I don`t think we have enough staff". CARE HOMES FOR OLDER PEOPLE Queenswood Care Home Cliffgrove Avenue Chilwell Nottingham NG9 4DP Lead Inspector Stephen Benson Unannounced Inspection 25th March 2009 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queenswood Care Home Address Cliffgrove Avenue Chilwell Nottingham NG9 4DP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0115 922 1037 0115 943 6245 kathryn.rafter@mha.org.uk www.mha.org.uk Methodist Homes for the Aged Mrs Margaret Wetton Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd October 2006 Brief Description of the Service: Queenswood is a Methodist Care Home providing personal care and accommodation for a maximum of 41 older people. The home is located in a residential area, one mile from Beeston town centre. The home has a minibus that is used for the service users to access local facilities and for other outings. The home was built for the purposes of a care home and the two-story building has level access. It is totally wheelchair accessible throughout with a passenger lift and other adaptations. All bedrooms are single and have ensuite toilet and shower facilities. There are well-maintained and accessible gardens providing seating areas outside. The manager said on 25/03/09 that the fees range from £367.00 to £517.00. There are additional charges for hairdressing and chiropody. Queenswood Care Home DS0000008735.V374726.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 the people who use this service experience good quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for people accommodated and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This was our first visit to the home since 1st April 2008. This inspection involved one inspector; it was unannounced and took place in the daytime, including lunchtime. Prior to the visit an analysis of the home was undertaken from information gathered over the last year including that from the Annual Quality Assurance Assessment they completed. We sent survey forms entitled ‘Have your say about…’ to a sample of people and 6 of these were returned. The main method of inspection used is called ‘case tracking’ which involves looking at the quality of the care received by a number of people living at the home. We also use evidence from our observations; we speak with them about their experience of living at the home; we look at records and talk with staff about their understanding of the people’s needs who they support. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. What the service does well: Anyone new coming to the home has their needs assessed to make sure they can receive the help and support they need. A recently admitted person said, “I already knew about this home, someone came to see me where I was”. Staff are learning to write person centred care plans, involving people living in the home, so they reflect the person’s wishes regarding their health and personal care. One person recently admitted said, “They have talked to me about help, they said don’t forget we are here if you want us” another person said, “I have a care plan and I have seen it”. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 6 People living in the home feel that they are respected and treated in a dignified manner. One person said, “They help me with washing and dressing, I feel comfortable how they help me”. There are activities organised every day and regular opportunities to worship and discuss religious beliefs. People commented, “They have things going on, I enjoyed the quiz at lunchtime” and “We had a choir com to sing to us, we get lots of different types of music, we all like music”. Visitors are welcome to come at anytime so people can keep in contact with family and friends and routines in the home are flexible to take into account people’s wishes. Food is well cooked and nicely presented. One person said, “I like to be able to help myself, and can have more if I want”. There is a complaints procedure, which is available for people to use. This has been used by people to raise things they are not happy about, which are then resolved. A person recently admitted said, “I was told not to bottle anything up and to complain if I need to”. There was information seen that told staff what they must do in order to make sure people are safeguarded. One person said, “Everyone is so kind to us”. The building was nice and clean and repairs are carried when needed. Improvements are being made to the décor making it a pleasant place for people to live. One person said, “The home is lovely, very nice and clean although it’s to hot” another person responded, “I don’t think so”. One person commented in a survey form, ‘Sometimes the rooms get very cold’ Staff know what they need to do to stop any infection spreading around the home, including wearing protective clothing. New staff can only start work when the required checks have been carried out, including a satisfactory Criminal Records Bureau or Protection of Vulnerable Adults check and obtaining satisfactory references. What has improved since the last inspection? There were not any requirements set at our last inspection. There have been improvements made to the décor and furnishings in several areas of the home. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Queenswood Care Home DS0000008735.V374726.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): 3 and 6 People who use 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. Information gathered during the assessment process is not being used to inform staff of new people’s needs. EVIDENCE: Information provided on The Annual Quality Assurance Assessment (AQAA) stated that there have been 33 people admitted to the home in the last 12 months and there have not been any placement breakdowns. A person who was admitted recently was one of the people case tracked, and there was a domiciliary pre admission assessment completed which was dated prior to the person moving into the home. A start had been made on the care plans. A member of staff was seen dealing with a telephone enquiry for a placement and completed an enquiry form. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 10 Staff were aware that an assessment is carried out for anyone coming to live at the home, but said they did not see these before the person moved in. The manager was surprised at this and said they are available in the office. A recently admitted person said, “I already knew about this home, someone came to see me where I was”. There is no arrangement made for the home to provide an intermediate care service. Queenswood Care Home DS0000008735.V374726.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 and 10 People who use 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 are involved in planning their own care and their health and personal needs are met by care practices in the home. Medication practices need to be strictly adhered to at all times. People’s privacy and dignity are promoted. EVIDENCE: A sample of four care files were seen and these contained assessments, risk assessments, care plans and monitoring charts. These were neatly written giving clear information about how people’s needs should be met. They contained useful information about people’s preferences, for example one plan seen stated which toothpaste the person preferred. There was also information about what people could do for themselves, one plan said the person could wash her face and hands but needs help to do her back. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 12 Plans were mainly written in the first person and showed when the person and/or their relatives were involved in preparing and reviewing them. The manager said plans were now 100 better than when she took up post and training is provided for staff on these. Staff also thought they were a lot better and spoke of reviewing them with people and their relatives. In the minutes of the last residents’ meeting it was recorded that staff would be discussing care plans with people. One person recently admitted said, “They have talked to me about help, they said don’t forget we are here if you want us” another person said, “I have a care plan and I have seen it”. There was information seen in care files about health promotion. One file showed a person who was admitted following a fall was complaining about a pain, so was taken to hospital where it was found she had a fracture. In our survey forms, ‘Have your say about…’ Everyone said they receive the medical support you need Staff were seen asking people how they were feeling and one person said not good to which the staff asked if she could do anything. Part of the morning and lunchtime medication rounds were observed and staff administering medication said they had received training in the safe handling, storage and administration of medicines. A new senior member of staff was observing the medication round as part of her induction. The deputy manager said they follow the home’s medication policy. One person was left some tablets to take at lunchtime and was not observed taking them. The manager said this should not happen and that staff should always observe people taking their medication. Staff were seen telling one person who was complaining of being in pain some of the tablets they had just taken were for pain relief and they would feel the benefit shortly. The medication for one person who was recently admitted was not stored using the monitored dosage system used by the home. The medication had been copied out onto a Medicine Administration Record and checked by another member of staff to be correct. Staff were seen contacting the pharmacist to sort out an error they had found when checking new medication into the home. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 13 One person said, “I am not able to medicate myself, I am given my tablets in the morning”. Staff said they promote people’s privacy and dignity through asking questions and where someone may forget their dignity responding quickly to this. The laundress was seen naming clothes to ensure they did not get mislaid. One person said, “They help me with washing and dressing, I feel comfortable how they help me” Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 14 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 People who use 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 living in the home have opportunities to satisfy their social, religious and recreational interests and needs through opportunities provided within the home, the local community and being able to maintain relationships. People are encouraged to exercise choice and control over their lives. Good catering arrangements could be improved further... EVIDENCE: There is an activities coordinator who organises activities each day, which are displayed on a whiteboard in a corridor. One person commented in a survey form that they found this useful. The activities coordinator showed a record of all activities and plans or activities over the coming months. One person who was case tracked had not taken part in any activities and it was recorded that the person spends all her time in her room. There were entries on the care file showing when staff had invited the person to take part in activities in the home but she had declined. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 15 There is a house Chaplin attached to the home who visits people in their rooms. There are weekly fellowship meeting, one took place during the inspection and was well attended. There are services on Thursdays and Sundays as well as fortnightly bible reading classes. People were asked in the residents’ meeting for suggestions for different activities. Some people were discussing a game of whist planned for the afternoon. The manager said she has got care staff to also be involved in providing activities for people. People commented, “They have things going on, I enjoyed the quiz at lunchtime” and “We had a choir com to sing to us, we get lots of different types of music, we all like music”. Some people go out to local churches and one person spoke of having been to stay with her daughter for a few days. Another person who recently moved into the home said, “Both my son and daughter have been to see me”. People are encouraged to put forward ideas and suggestions in residents’ meetings, and the minutes showed people were asked for suggestions about décor and food as well as being able to be involved in the selection of new staff. One person prefers to sleep in her armchair at night and has all meals in her room. Staff said they respect the person’s choices, although do try to encourage her to spend some time in bed and offer her to join in communal meals. There is a four week menu, which has had a number of changes made, which the cook said was as a result of requests made. There is a choice provided at lunch and tea. The menu shows there is a roast meal on Sundays and a fish dish on Fridays. One person commented when asked what she thought of the food, “casserole, casserole, casserole”. Another person said, “We do have quite a lot of casseroles but they are different, they have to cater for a lot of us. It would be nice to have a lamb chop sometimes, but perhaps they haven’t got the space to do it”. The menu showed that there were three casseroles in one week and two in others. The manager said this was something that needed to be changed. Other comments made were about the quality of the meat, several references were made that it was tough and one person wrote on a survey ‘Quality of meat is not good at the moment the butcher had last year was excellent’. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 16 Staff said they sometime have to cut meat up for people because it is tough. Lunch today was a choice of gammon and pineapple or an omelette and people were seen choosing both options. A choice of drinks was provided. The meal was well presented with vegetables and parsley sauce in serving dishes on the tables. One person said, “I like to be able to help myself, and can have more if I want”. The dining room was out of action as has just been decorated and a new carpet being laid. The temporary arrangements in the lounges provided a comfortable place for people to dine and tables were well presented with linen cloths and flowers on. People said they had enjoyed their lunch. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 17 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 People who use 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 encouraged to raise anything they are not happy about and staff know how to protect them and ensure their safety. EVIDENCE: Information provided on The Annual Quality Assurance Assessment, which was received in September 2008, showed that there have been 6 complaints made in the last 12 months. The complaints log showed that appropriate action had been taken to resolve complaints. One had resulted in a member of staff being dismissed for using someone’s personal telephone and the manager said the person had bee n referred to the Protection of vulnerable Adults register but had not been accepted due to the small amount of money involved. There was an entry seen in the residents’ meeting minutes reminding people of the complaints procedure if there is anything they are not happy about and a book in the entrance hall for anyone to write any complaint. A person recently admitted said, “I was told not to bottle anything up and to complain if I need to”. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 18 Staff were aware of the Nottingham and Nottinghamshire Safeguarding Adults Policy, Procedure and Guidance for Alerters and Referrers and of the home’s whistleblowing policy. There was information about ‘No secrets’ in the entrance hall. Staff said they had taken part in some in house safeguarding training over the last week and had completed some booklets. The manager said this training was passing on a course she had attended with Nottinghamshire County Council. One person said, “Everyone is so kind to us”. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 19 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 and 26 People who use 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 live in a safe, well-maintained environment, which is clean, pleasant and hygienic EVIDENCE: There have been a number of areas decorated in the last year and the dining room was just being completed with a new carpet being laid. Minutes of the residents’ meetings said that other areas of the home are due to be decorated shortly. Staff said they record any repairs needed in a repairs book which are then carried out by the handyman. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 20 In our survey forms entitled ‘Have your say about…’ everyone said that the home is always fresh and clean. In a satisfaction survey carried out by the manager it stated that 87.32 of people were satisfied with the cleanliness. One person said, “The home is lovely, very nice and clean although it’s to hot” another person responded, “I don’t think so”. One person commented in a survey form, ‘Sometimes the rooms get very cold’. Information provided on The Annual Quality Assurance Assessment stated that there is a policy at the home for preventing infection and managing infection control and that 26 staff have received training on the prevention of infection and management of infection control. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 21 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 People who use 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 are not having their needs met in good time due to current staffing arrangements. People are supported and protected by the home’s recruitment policy and practices. EVIDENCE: Information provided on The Annual Quality Assurance Assessment showed that there are 27 care staff and a further 18 support staff employed. Ten care staff have left the home in the last 12 months. There have been 28 shifts covered by agency staff in the past three months. There are 4 care staff and a senior care on each shift. Staff commented that they do not think there are enough staff on duty and as a result they are still getting people up at 11.00am sometimes. One person was not got up until 11.30am today, but did not wish to answer any questions, so the reason for this could not be established. The call bell alarm was heard going off for long periods before staff attended, one incident was timed in excess of 5 minutes. One of the domestic staff was seen helping people into the lounge for the fellowship meeting and staff said this was because they needed help. Staff Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 22 also said sometimes only one carer has got someone up where the care plan says it should be two. In our survey forms ‘Have your say about…’ Three people said staff were always available when you need them and three people said they usually are. One person commented ‘Sometimes seem a long time answering bell’. Another person wrote, ‘Fell in tea bar and had to wait for another resident to hear shouting and call for help’. One person said at 10.00am “You try and find staff now, you won’t find one. I don’t think we have enough staff”. There were not any staff situated in the lounge until 10.30am when morning drinks were provided. Another person said, “I don’t think there are enough staff as we have people with dementia”. The manager said that a new rota is coming into operation from 13th April 2009 and this will be monitored by the senior carer on duty. Information provided on The Annual Quality Assurance Assessment showed that there are 29 care staff who have National Vocational Qualification level 2 or above and a further 3 working towards one of these. The manager said that 2 new staff have got level 2. Staff spoken with said they had either completed a National Vocational Qualification level 2 or 3 or were in the process of doing so. It was recorded on The Annual Quality Assurance Assessment that all people who have worked in the home in the past 12 months had satisfactory pre employment checks. Staff files seen showed that the correct recruitment practices are followed. The home follows their equal opportunities policy in the recruitment of new staff. A sample of staff files seen showed the correct recruitment practices were followed. A recently appointed member of staff said she had undergone the required pre employment checks but had not completed her induction book yet as she had not had enough time. Information provided on The Annual Quality Assurance Assessment showed that all catering staff and 65 of care staff have received training in safe food handling. It was also stated that the home has a staff development programme appropriate for the service they provide. Staff said they have good training opportunities and spoke of courses they have recently attended, but said they have not had any training on working with people with dementia, and would like this to be provided. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 23 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 and 38 People who use 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. There is a suitable manager in post and there are management systems in place for the smooth running of the home and to ensure people are protected. People are empowered to express their views on how the home is run. EVIDENCE: The manager, who has successfully completed the registration process, has been in post since the February 2008. The manager has previous experience of managing a care home and has successfully completed the Registered Manager’s Award and undertaken National Vocational Qualification level 4. There are residents’ meetings where people are consulted on their views and they can put forward any suggestions. The results of the survey undertaken in Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 24 September 2008 were discussed at one meeting and a copy of these was available in the entrance hall. The results showed an overall satisfaction with the home and there were a number of individual comments about personal experiences. There is a system for people to receive assistance in managing their money to pay for hairdressing, chiropody and other incidentals. A record is made of each transaction and signed and witnessed. Receipts are kept when available. The manager said that all the required health and safety checks are carried out at the required frequency and there are service contracts in place for servicing all the equipment. It was stated on the Annual Quality Assurance Assessment that equipment is tested or serviced as recommended by the manufacturers or other regulatory body. Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 25 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 13(2) Requirement Staff must not leave medication with people to take later. This will ensure that people living in the home take the medication they are meant to. There menu must provide sufficient variety of dishes. This will ensure people do not find their meals repetitive There must be sufficient staff on duty at all times. This will ensure that staff are available to meet residents’ needs. Timescale for action 01/04/09 2 OP15 16 (2)(i) 01/07/09 3 OP27 18 (1)(a) 01/06/09 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 2 Refer to Standard OP3 OP15 Good Practice Recommendations Ensure staff are aware of the content of assessments for new people moving to the home. Ensure the quality of meat provided is of an acceptable standard. DS0000008735.V374726.R01.S.doc Version 5.2 Page 27 Queenswood Care Home Queenswood Care Home DS0000008735.V374726.R01.S.doc Version 5.2 Page 28 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. 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