Inspection on 05/07/07 for 11 Kilford Court

This inspection was carried out on 5th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

11 Kilford Court 30/06/09

11 Kilford Court 11/10/06

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 2TN Lead Inspector John Vaughan Unannounced Inspection 5th July 2007 09:45 11 Kilford Court DS0000059147.V341306.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.V341306.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.V341306.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 11 Kilford Court Address Mortimer Road Botley Southampton Hampshire SO30 2TN 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) elmo82@hotmail.co.uk www.choicesupport.org.uk Choice Support Position Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 11 Kilford Court DS0000059147.V341306.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. 11th October 2006 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.V341306.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector met with people using the service, staff members and the new manager of the home during the visit to the service, which took place over one day. During the visit the inspector spoke to people about their experiences of the home, observed people and staff, sampled records, interviewed staff and looked and the facilities and environment provided for people who live in the home. The inspector also reviewed information held by the commission including previous reports, incident reports and the Annual Quality Assurance Assessment (AQAA) provided by the manager of the service. What the service does well: People benefit from a well managed and varied activity programme that has been put together based on their individual needs and interests which includes trips out, walks, shopping, gardening, swimming and holidays. Detailed care plans support the people with their assessed needs and these are reviewed with the individual on a regular basis. The home has a very comfortable and relaxed atmosphere and people who use the service and staff talked openly together. The inspector saw positive contact between the staff and people who live in the home. A menu plan has been developed to give choices to individuals on a daily basis and people said they liked the choices being offered. People are supported and encouraged to keep in contact with families and friends. The home is clean and tidy and free from any unpleasant smells. Rooms are light and bright and have been decorated to a good standard. People who use the service told the inspector that they were happy with their private rooms. The home provides a good level of staff who are experienced to meet the needs of people and these staff are supported to develop their skills through a good training and development programme. 11 Kilford Court DS0000059147.V341306.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. 11 Kilford Court DS0000059147.V341306.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.V341306.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. 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 this service. People who wish to use this service can be confident that their needs will be fully assessed before they move into the home. EVIDENCE: There have been no new admissions to the home for over 4 years. The last inspection of the service confirmed that the service has an admission process that it would follow in the event of a place becoming available. Local Authority assessments would be obtained and the manager would also carry out a full assessment of the person’s needs. The views of people who already live in the home would be taken into account and the compatibility of others who use the service would be considered. 11 Kilford Court DS0000059147.V341306.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are supported by an established care planning and risk management system that responds to their assessed needs and helps them to make choices about their everyday lives. EVIDENCE: The inspector looked at three care plans for people who use the service. Each of these plans had clear and specific information covering all areas of daily life. These plans are regularly reviewed and updated by the manager and the person’s key worker. Detailed guidelines and strategies are contained within the plans giving staff information on how to support the people who use the service. Communication strategies are in place to help staff to understand the best way of involving the individual in daily life. 11 Kilford Court DS0000059147.V341306.R01.S.doc Version 5.2 Page 10 The manager told the inspector about the additional pictorial person centred plans. These cover areas that are important to the individual and were completed with the input of the individual and others who know the person best. Reviews of these plans took place on the day before the inspection visit. The manager told the inspector that they are hoping to scale down the current format of these plans from the current poster size to make them easier to use. During the visit to the home the inspector observed staff interaction with people who use the service. The approach of staff members supported people to make choices and understand what was happening during activities. A number of people have sensory impairments and the staff gave information and guidance in sensitive and meaningful ways to meet their needs. Support plans are also in place to provide guidance for staff on how to support people with sensory needs. Throughout the visit staff were seen to offer people choices and support to make decisions about meals, drinks and preparation for activities. Two formats are currently in place for risk assessments in the home. A more accessible format has been introduced to help involve people in managing risks and the manager said that they are gradually switching all assessments to this format. Areas covered include day-to-day activities inside and out of the home, medication, pressure care, mobility and behaviour. 11 Kilford Court DS0000059147.V341306.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service continue to benefit from a wide range of activities based on their assessed needs, interests and hobbies together with a balanced and varied menu offering choices and healthy options. EVIDENCE: All people who use the service have a day service programme of activities and this covers educational and vocational activity. A record of these activities is maintained in order to evaluate the suitability of activities. On the day of the visit people were out participating in swimming/hydrotherapy sessions with a further trip out for another person planned for the afternoon. 11 Kilford Court DS0000059147.V341306.R01.S.doc Version 5.2 Page 12 People are supported to go out into the local community shopping, visit local pubs and cafes and attend fetes, attending morning services at a local church every Sunday and community events in the local area. The manager said that they are raising their community profile and this year they have entered “Botley in Bloom”. The inspector noted plenty of activity in the garden preparing flowerbeds and tending to flowers and plants. One person said that they enjoy the garden and are supported to help with the gardening. People are supported to maintain family relationships and some people have regular visits from family members. One service user has a friend at another local home and staff support them to visit. The inspector saw care plans which recognised important relationships and provided guidelines on how to maintain these contacts. Daily routines in the home promote the independence of people who use the service. Staff were observed knocking on doors before entering. One person has a hearing impairment and the manager pointed out that they haves a light switch outside his room so that staff can flash the lights in order to get the person’s attention before entering the room. The inspector spoke to one of the people who use the service about their experiences of living in the home. The person said that they enjoy living in the home and commented “its my home”. The person confirmed that they have regular activities and that they receive support from the staff team to meet their needs. Recently the person has been on train trips and a boat trip to the Isle of Whight is planned for next week. Meals are generally eaten together as a group however some people prefer to eat alone and these wishes are respected. The inspector was told by one of the people who lives in the home that the food is very good. The meal observed by the inspector was unhurried and staff provided sensitive support to people who need assistance to eat and drink. A menu plan was seen and this was balanced and varied. 11 Kilford Court DS0000059147.V341306.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical and emotional needs of service users are well met and improvements to the medication practices demonstrate that people using this service are kept safe. EVIDENCE: The inspector saw evidence of contact with General Practitioners, dentists and specialist consultants and a record is maintained of contact with health professionals. Care plans are in place to support people with their healthcare needs. On the day of the visit the inspector noted that the district nurse visited the home to provide treatment to an individual with a pressure ulcer. The person’s care plan documents the preventative measures in place to minimise the risks of further breakdown of the area. 11 Kilford Court DS0000059147.V341306.R01.S.doc Version 5.2 Page 14 At the last inspection concerns were raised about gaps in medication administration records and the lack of clear guidance on when required medication. The medication is stored in a secure cabinet. Medication records were checked and found to be up to date and accurately completed. The manager stated that the assistant manager checks the records weekly as part of their stock check. The manager is now carrying out six monthly competency assessments for all staff who administer medication. The inspector noted clearer information on the use of when required medication, which is generally for pain relief. Authorisation from a person’s general practitioner to crush their medication is also on file and an appropriate device was in place to crush this medication. The manager was advised to look at the cleaning routine for the tablet crushing device as it had a lot of residue from previous use. 11 Kilford Court DS0000059147.V341306.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service can be confident that their views would be listened to and acted upon, complaints would be logged and responded to appropriately. The homes policies and procedures help to protect people from abuse. EVIDENCE: The home has a complaints procedure that has been made more accessible to people who use the service. The complaints log was seen confirming that now complaints have been made since the last inspection. 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. The manager provided information to the commission as part of the Annual Quality Assurance Assessment (AQAA) to state that further work is underway with other agencies to develop the policies and procedures used by the service. 11 Kilford Court DS0000059147.V341306.R01.S.doc Version 5.2 Page 16 The assistant operational manager spoke to the inspector about this work which includes the development of more accessible policies, working with people who use the service to obtain the views and feelings on keeping and feeling safe and training for the staff team. 11 Kilford Court DS0000059147.V341306.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service benefit from a well maintained and comfortable home enhanced by individually personalised private rooms and an attractive and accessible garden. EVIDENCE: People allowed the inspector to view their private rooms. These rooms were decorated to their personal tastes with pictures, posters and personal items. Equipment is in place to improve accessibility for people who have mobility difficulties. 11 Kilford Court DS0000059147.V341306.R01.S.doc Version 5.2 Page 18 The inspector saw a well maintained home and the furniture and fixtures in the communal areas were of good quality. Part of the lounge is used as a sensory area for people to relax in. The home was clean, tidy and free from any unpleasant smells and a utility room contains washing and drying facilities and people are encouraged to take part in the every day housekeeping tasks. The home has a large garden set out with flowerbeds, lawn and vegetable patch and this is very well maintained. Staff and people who live in the home take part in the upkeep of this area and use the vegetables in the home. 11 Kilford Court DS0000059147.V341306.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Well-trained and supervised staff members support people who use this service. The recruitment practices demonstrate that a thorough recruitment procedure is now followed in the home however the maintenance of records needs to be improved. EVIDENCE: The inspector looked at the records for five of the staff who work in the home and spoke to the manager about recruitment practices. The records available in the home were not very well organised and the manager found it difficult to see what was available for each member of staff. The inspector saw evidence of two written references, application forms and proof of identity. The information on Criminal records bureau Checks (CRB) was not available for four of these records. The organisation has an agreement with the commission to hold all records centrally on the condition that they keep a detailed record of what information 11 Kilford Court DS0000059147.V341306.R01.S.doc Version 5.2 Page 20 has been obtained in the home. The assistant area manager contacted the inspector with full details of each of the staff members confirming that CRB checks have been completed. The also stated that the records are being reorganised and the agreed record will be put in place. There is a good mix of staff skills and experience in the home and all staff are encouraged and supported to undertake NVQ training. The inspector spoke to staff who confirmed that they undertake induction training Mandatory training is carried out in; moving and handling, fire safety, medication, first aid, health and safety, food hygiene and infection control. Additional courses are available that they could request to go on and training needs were discussed at supervision sessions. 11 Kilford Court DS0000059147.V341306.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is managed in an effective and open manner, a system is in place to develop the service with views from service users and their families included in this process and the home’s equipment is maintained and serviced to keep people safe. EVIDENCE: Since the last inspection the registered manager has left the service. A new manager has been appointed and they have worked in the home for some time so is familiar with the needs of the service and the people who use it. The inspector was told that they receive support from their line manager and they will be undertaking their NVQ 4 and Registered Manager’s Award as soon 11 Kilford Court DS0000059147.V341306.R01.S.doc Version 5.2 Page 22 as possible. Comments on the management style and support from the management team were positive from the staff team. The views of people who use the service are obtained through staff interaction and this is fed back to the manager through team meetings and also key worker meetings and care planning reviews. 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 organisation has engaged the services of another agency who support people with a learning disability to develop the consultation processes to improve surveys and the in put of people in the service development programme. The inspector confirmed by examining the homes servicing records and in formation supplied by the manager in the AQAA that the alarm system has been serviced regularly. Weekly alarms tests are completed, a fire drills and staff training in fire safety take place regularly. A weekly inspection of all fire fighting equipment takes place. 11 Kilford Court DS0000059147.V341306.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 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 3 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 3 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 3 X 3 X 3 X X 3 X 11 Kilford Court DS0000059147.V341306.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 11 Kilford Court DS0000059147.V341306.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 11 Kilford Court DS0000059147.V341306.R01.S.doc Version 5.2 Page 26 - 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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