Inspection on 11/10/06 for 11 Kilford Court

This inspection was carried out on 11th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

11 Kilford Court 30/06/09

11 Kilford Court 05/07/07

11 Kilford Court 09/09/05

11 Kilford Court 14/10/04

11 Kilford Court 05/04/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 11 Kilford Court Mortimer Road Botley Southampton Hampshire SO30 2EN Lead Inspector Michael Gough Unannounced Inspection 11th October 2006 10:00 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 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 11 Kilford Court DS0000059147.V314118.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 Adults 18-65. 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. 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 11 Kilford Court Address Mortimer Road Botley Southampton Hampshire SO30 2EN 01489 790949 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) Choice Support Mrs Claire Hoyle Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users must be at least 45 years of age. 2 servcie users (21/08/1935 & 19/2/1928) to be accommodated in the LD(E) category. 9th September 2005 Date of last inspection Brief Description of the Service: 11 Kilford Court is purpose built as a residential care home for people who have learning disabilities and associated physical disabilities. There are four bedrooms on the ground floor, which are fully wheelchair accessible, and two bedrooms upstairs for service users who are more physically able. The home is situated on a small housing estate in Botley, approximately a quarter of a mile from local shops and pubs and access to public transport services. The home has a minibus that is equipped to provide transport for physically disabled service users. The home is managed by Choice Support. As well as residential care, the home provides day service activities for the service users. Fees at the home £984.06 per week. Service users are responsible for paying for their own toiletries and items of a personal or luxury nature. 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection took place on the 11 October 2006 commencing at 1015, the inspection took place over 5.5 hours and the inspector was assisted throughout by the homes manager. Evidence for this report was obtained by reading and inspecting records, touring the home and from observing the interaction between staff and service users. The inspector also has the opportunity to speak with the registered manager, three members of staff and one service user. It was not possible to gain the views of all the service users due to their verbal communication difficulties. What the service does well: What has improved since the last inspection? What they could do better: The inspection report will make 2 requirements to the home, which will help improve the service provided for residents. Generally medication procedures at the home are satisfactory, however there are a number recording errors on medication administration sheets where medication has not been signed as being given. There is also a lack of information for staff for administering “when required” medication. This could potentially put service users at risk. 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 6 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. 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. Prospective service users aspirations and needs are assessed before they move into the home. EVIDENCE: There have been no new service users admitted to the home for over 4 years. However the home has an admission process that it would follow in the event of a place becoming available. Local Authority assessments would be obtained and the homes manager would also carry out an assessment of needs. Existing service users views would be taken into account and the compatibility of others living in the home would be considered. 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. Service users assessed needs and personal goals are reflected in an individual plan of care and service users are supported to make decision about their lives with assistance given by staff. Service users are supported to take responsible risks and this allows service users to live an independent lifestyle as much as possible. EVIDENCE: Care plans were inspected for 2 service users and these were comprehensive documents and were clear and easy to follow, they gave clear information for staff on the support each service user requires and detailed how and when this support should be given. All service users have a key worker and there are meetings held every 4 – 6 weeks when Key workers carry our reviews of care plans then inform staff if any changes have been made. Service users are not able to take part in meetings, however there is evidence in daily notes which show that service users are involved in making informed decisions and comments such as “ decided that he would like to go into Botley 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 10 today” “refused day service today, went for a walk instead” and “asked if she wanted to go to the pub this evening, decided not to go, stayed in and watched video” were recorded. Because of the communication needs of most of the people living at 11 Kilford court, gauging their views involves knowing the service users and observing their responses to different situations. The inspector observed staff interacting with service users and taking their views into account. Service users care plans contained risk assessments and these gave details of the assumed risk the service users understanding of the risk and the support required and the action to be taken to minimise any identified risk. 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. Service users are supported to take part in age, peer and appropriate activities and they access the local community on a regular basis. The homes visiting policy supports service users to maintain family links and friendships both inside and outside the home and service users rights are respected. Service users are offered a healthy and varied diet and service users enjoy their meals at the home. EVIDENCE: None of the service users at the home undertake any form of paid employment however one service user is on a waiting list to be a volunteer at a local animal charity and staff will support her if she is able to do this. One service user goes to a local college through the day service and is participating in a course in “working with materials”. All service users have a day service programme of activities and educational and vocational training can be incorporated into individual day service programmes if required. 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 12 All service users require staff support to go out into the local community and they go shopping, visit local pubs and cafes and attend fetes and community events in the local area. Service users are well known in their local community and go into town on a regular basis. One service user is supported to attend morning service at a local church every Sunday and the religious needs and wishes of service users are respected. All of the service users at the home are on the electoral register and are eligible to vote. Service users are supported to maintain family relationships and 2 service users have regular visits from family. One service user has a friend at another local home and staff support her to visit. There is a clear visiting policy and the inspector was informed that staff would respect service users wishes on who they wish or do not wish to see. Daily routines in the home promote service users independence as much as possible, staff were observed knocking on service users doors before entering and seeking permission for them and the inspector to visit their rooms. One service user who is hard of hearing has a light switch outside his room so that staff can flash the lights in order to get the persons attention before entering the room. Staff were observed interacting with service users and their preferred form of address was used. One service user who was able to communicate with the inspector said that the daily routines in the home respected his rights to be involved as much or as little as he wanted. Mail is given to service users unopened and staff support is given to service users with their mail as required. Menu’s at the home are made up each week by the staff and take into account service users likes and dislikes and also their nutritional needs. Service users are offered a choice of cereals at breakfast and lunch is normally a snack type meal with the main meal being in the evening. The menu is flexible and allows for change at short notice and this gives service users the opportunity to choose a take away if they wish. A record of what each service users has to eat is kept at the home. Service users are encouraged to help prepare meals at the home as much as their abilities will allow and service users assist with making drinks and laying and clearing the table. Service users are encouraged to have their meals at the dining table in the kitchen but may choose to eat elsewhere if they so wish. On the day of the inspection staff were observed supporting service users with their lunch and the support was appropriate and service users were not rushed 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. 19 & 20 Quality in this outcome area is “adequate”. This judgement has been made using available evidence including a visit to the service. Service users receive personal support in the way they prefer and service users physical, emotional and health needs are met. However recording errors on medication administration sheets and the lack of information for staff regarding “when required medication” could put service users at risk of the mal-administration of medication. EVIDENCE: Personal support is given flexibly and service users plans give clear information to staff on how service users would like their personal support to be given and this allows for a consistent approach. Each service users has a key worker and service users have been involved as much as possible in their selection. Personal support is given in private and the preferences of service users on who they prefer to give them the support they need is respected. The home has a policy on cross gender care and if at all possible same sex care is offered and given. 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 14 All of the service users at the home are registered with the same GP surgery, however some have different GP’s. Service users have specialist input from the local learning disability team, from district nurse’s, occupational and speech therapists and physiotherapists. Dental checks and treatment are provided by a local dental clinic and a visiting optician calls once per year. Staff at the home monitor service users health and support service users to access appropriate healthcare professionals and to attend any appointments. The homes medication policy and procedures were examined and discussed with the homes manager. The information for the receipt, storage, disposal and administration of medication was clear, however there was no protocol or information regarding “when required” medication. Although at present when required medication was limited to paracetamol, it was unclear how any decision was made to give pain relief or who made this decision. A requirement was made for the home to provide clear information for staff on the procedures and protocol for administering when required medication. Medication administration records were checked for the last 7 days and there were 24 gaps where medication had not been signed for. The manager stated that this was an ongoing problem that the home was trying to address. A requirement was made that the home must ensure that the home keep a clear up to date record of the date and time for all medicines administered to service users. This is a partial repeat requirement from the inspection of the 9 September 2005 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. There is a clear and accessible complaints procedure, which includes timescales for the process and service users can be confident that their views would be listened to and acted upon, any complaints are logged and responded to appropriately. The homes policies and procedures help to protect service users from any form of abuse EVIDENCE: Service users were not fully aware that the home had a complaints procedure due to their learning disability, however all relatives are given a copy and a copy is displayed on the notice board at the home and this contained all of the required information and gave details of how to contact the CSCI. One service user has an independent advocate and the other service users are supported by an advocacy service, which is based in Southampton and they have visited the service users at the home and have been given a copy of the complaints procedure. There have been no complaints made to the home since the last inspection, however there have been some concerns raised by neighbours regarding parking issues at the home. Staff members spoken to were aware of the complaints procedure and knew how to raise any concerns on behalf of service users. The home has a copy of the Hampshire Adult Protection procedure and has a whistle blowing policy and a copy of the department of health guideline “No Secrets” Staff also receive training with regard to adult protection and the protection of vulnerable adults as part of their induction. Staff members spoken to confirmed that they had received training and were aware of their responsibilities in this area. 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. Service users live in a homely and comfortable environment and the home is clean and hygienic and free from offensive odours. EVIDENCE: A tour of the home was conducted and all areas of the home were pleasantly decorated with good quality furniture and fittings. The service was homely in appearance and the downstairs area of the home was wheelchair accessible. The home was clean and hygienic and there were no offensive odours, there is a utility area adjacent to the kitchen, which has washable floors and walls. There is an industrial tumble drier and also an industrial washing machine with sluice facility and this is able to wash clothing at appropriate temperatures. Service users are encouraged to bring their own laundry down to the utility room and staff support service users to do their washing. There is information, which gives staff clear guidance for washing any soiled items. The home has an infection control policy and staff have received training in this area. 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. Competent, qualified and appropriately trained staff supports service users and meet their needs. The homes recruitment policy and practice protect service users. EVIDENCE: There is a good staff mix at the home and all staff are encouraged and supported to undertake NVQ training. Currently the home has 4 members of staff who have completed NVQ. The home is part of Choice Support and recruitment is carried out through the organisations human resources department and a panel of managers carries out interviews, whenever possible service users are involved in the interviewing process. 3 recruitment records were inspected these contained all of the required information, including application forms, 2 x references and criminal records bureau checks. The organisation has a training co-ordinator who arranges training for all staff employed at Choice Support homes. Staff undertake induction training, which consists of 4 booklets and these are linked to NVQ, the booklets are expected 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 18 to be completed within the first 12 weeks of employment. Mandatory training is carried out in; moving and handling, fire safety, medication, first aid, health and safety, food hygiene and infection control. Staff members spoken with confirmed that they had received a good induction and said that there was a booklet with a list of courses they could request to go on and training needs were discussed at supervision sessions. 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is “good”. This judgement has been made using available evidence including a visit to the service. Service users benefit from a well run home and the views of service users and other interested parties are sought on how the home is meeting service users needs. The health, safety and welfare of residents and staff are protected. 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager at the home has completed the registered managers award and is currently undertaking NVQ4. She has a clear job description, which sets out her roles and responsibilities and she has been managing the home for the past 2 years. She undertakes regular training to update her skills. The views of service users are obtained through staff interaction and this is fed back to the manager through team meetings and also key worker meetings. The organisation has its own quality assessment process and all services are audited annually. Quarterly newsletters are sent out to relatives and friends and questionnaires are sent to service users. The manager is fully aware of her responsibilities with regard to Health & Safety and there is a risk assessment for the building and monitoring takes place. The fire logbook was inspected and all appropriate testing and checks have been recorded. Appropriate certificates were in date for gas safety (June 06), fire alarms systems and equipment (May 06), private electrical equipment (June 06), fixed hoists (August 06) and the homes hot water system (Feb 06). 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 3 X 3 X X 3 X 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) 17(1)Sch 3 Requirement The home must ensure that a clear and accurate record of the date and time of all medicines administered to service users is kept at the home. This is a partial repeat requirement from the inspection on the 9/9/05 The home must provider clear information and guidance for staff regarding the administration of “when required” medication Timescale for action 06/11/06 2. YA20 12(1)(a) 15/12/06 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 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 11 Kilford Court DS0000059147.V314118.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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