Inspection on 22/03/07 for Kingsmead Lodge

This inspection was carried out on 22nd March 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

Kingsmead Lodge 17/10/05

Kingsmead Lodge 20/06/05

Kingsmead Lodge 08/12/04

Kingsmead Lodge 29/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Kingsmead Lodge Crawley Road Roffey Horsham West Sussex RH12 4RX Lead Inspector Mrs J Hough Unannounced Inspection 22nd March 2007 08:50 Kingsmead Lodge DS0000024164.V331470.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 Kingsmead Lodge DS0000024164.V331470.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. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsmead Lodge Address Crawley Road Roffey Horsham West Sussex RH12 4RX 01403 211790 01403 210424 mundopa@yahoo.co.uk 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) Dr Shafik Hussien Sachedina Mr Shiraz Boghani Miss Eunice Mundopa Care Home 20 Category(ies) of Physical disability (20) registration, with number of places Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only service users with a physical disability may be admitted, some of who may also have a learning disability. 17th October 2005 Date of last inspection Brief Description of the Service: Kingsmead Lodge is a care home with nursing that is registered to provide a service to twenty people who are between the ages of eighteen and sixty-five years and who have a physical disability (PD). A condition of registration is that only service users with a physical disability may be admitted, some of whom may have a learning disability.Kingsmead Lodge is a purpose built, single storey building located on the outskirts of Horsham in West Sussex. There are twenty single rooms with en-suite facilities that include a toilet and wash hand basin. There is a large activities room, a small quiet lounge, two dining rooms, a sun lounge and a spa pool. There is an enclosed sensory garden and an indoor sensory room. Sussex Health Care own Kingsmead Lodge. The owners and responsible individuals are Dr S Sachedina and Mr S Boghani. The registered manager is Miss Eunice Mundopa who is responsible for the day-to-day running of the home. Kingsmead Lodge is on the same site as another care home that is owned by the Sussex Health Care Group. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection was undertaken by June Hough Regulatory Inspector on 22nd March 2007 from 08:50 hours to 15:00 hours. Information and planning for the inspection process was taken from the preinspection questionnaire completed by the registered person, and evidence from the previous inspection carried out in October 2005. Further evidence for this inspection report was gained during the inspection site visit. Resident and relative surveys were sent to the home but none were completed and returned to the Commission of Social Care Inspection. During the inspection a tour of the premises was made, and records were seen in relation to resident’s care plans and assessments, complaints, accidents and medication. Residents, relatives and staff were spoken with and the registered manager provided any information required. There was one recommendation made as a result of the inspection site visit. The current scale of charges are from £1200.00 to £2100.00. What the service does well: The residents are provided with a variety of activities both in house and in the local community. Some residents attend local day centres and local colleges. The home makes arrangements for residents to go on holiday each year to a destination of their choice. The home being purpose built is light and spacious and residents are able to personalise their rooms with their own belongings and in some cases choose the colour scheme for their room The residents are supported to maintain their independence as much as possible and are given choices in all aspects of their care and what they want to do. Observations of staff showed that they are dedicated in their work and showed a commitment to providing the residents with the care they required. Staff said that they are supported and encouraged by the organisation to attend the training necessary for their work. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 6 The home is well run and managed by a competent and experienced manager. Residents, staff and visitors felt the manager was approachable and communitative giving them opportunities to express their views and discuss any matters in relation to the home. What has improved since the last inspection? What they could do better: There was one complaint received that was dealt with following the home’s complaints procedures but was not recorded in the complaints log giving details of the investigations, actions and outcome. As part of the quality assurance system within the home surveys are sent to residents and relatives. It was advised that surveys be sent to stakeholders in the community such as other health professionals, in order to gain a wider view on the quality of services provided by the home. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 8 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 Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 9 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): Quality in this outcome area is good. Prospective residents have a detailed needs assessment carried out prior to any agreement being made for the resident to move into the home to ensure the home is able to meet the individual needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been one new admission to the home since the last inspection. A detailed pre-admission assessment was carried out by the registered manager. Relatives are involved in the completion of assessments. All new residents move into the home for a three months probation period followed by a review to ensure the needs of the resident are being met. The Service User Guide provides information about the home and is available in a suitable format for residents. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have a detailed person-centred care plan that includes all their assessed needs and personal goals and takes into account their wishes about how they are looked after and what they want to do. Residents are supported to take reasonable risks that are identified on individual risk assessments. EVIDENCE: Three resident’s care plans were read in detail and care plans were personcentred giving a detailed account of the needs of residents in relation to their Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 11 health, personal and social care needs. Resident’s views and wishes about the way care should be provided had been taken into account. Risks had been identified and assessed to ensure the protection of residents. Care plans were signed by relatives where possible as evidence of their involvement in the completion of plans. The home has a designated nurse for wound care and a wound care chart is completed for residents with pressure sores or skin problems giving a detailed description of the treatment required. Advice and support is requested from the specialist tissue viability nurse based at the local hospital when needed. All residents have a key worker who is involved in the updating of care plans with the registered nurse. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported and encouraged to participate in a wide variety of activities of their choice within the home and the local community. Residents are supported to maintain links with family and friends and visiting arrangements in the home are flexible. Residents are offered a good variety of nourishing food and menus are developed taking into account the resident’s likes and dislikes in food. EVIDENCE: Residents have opportunities to participate in a variety of activities within the home and the local community. Residents attend local colleges and day centres of their choice. The home has the facility of a sensory room and spa bath. There is an active programme of activities within the home with a large activity room. An activity co-coordinator plus two activity assistants facilitate the Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 13 activities that include music sessions, games, computer sessions, arts and crafts, gardening etc. On the day of the inspection residents were making decorations to hang in the activity room for Easter. Outings are arranged to local theatres, cinema, bowling, parks and seaside resorts and parks. Arrangements are made each year to take the residents on a holiday of their choice. The home has a physiotherapist and assistants that provide residents with various exercises. On the day of the inspection some residents were seen using standing frames and others lying on large bean bags. Passive exercises were included and some residents were enjoying a massage from the aromatherapist. Family and friends are encouraged to maintain contact with residents and visitors spoken with on the day of the inspection said they can come and go as they please and are made welcome by staff. The home maintains strong links with families and relies on them for much of the information with regard to resident’s needs. Observations of staff showed that they knocked on resident’s doors before entering their rooms. All doors to resident’s rooms are fitted with internal locks that can be accessed by staff in an emergency. Notices were displayed on some of the resident’s doors who have communication problems telling staff how they wanted them to enter their room. Residents are offered a choice of suitable and nutritious food and menus are set for a four-week period taking into account resident’s likes and dislikes in food. Menus are reviewed regularly and changed as required. Special diets are catered for and where residents are artificially fed this was seen being carried out by staff in a sensitive and caring manner and at times that did not restrict the resident’s chosen daily routines. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s preferences and choices in the way they are cared for are documented on care plans and followed by staff. The home has policies and procedures on medication to ensure safe practice in the administration of resident’s medicines. Residents have access to specialist medical services as required . Residents have the specialist equipment and aids needed to ensure their maximum independence. EVIDENCE: Care records and care plans identify the preferences, wishes and needs of residents in all aspects of their care. Sections in the assessment process indicate preferred times for getting up and going to bed and care plans identify what the resident is able to do for themselves and what they need help with. Assessments include what matters to me, things that are working out and not working out in my life, my dreams, likes and dislikes, and spiritual care. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 15 The home provides residents with the special equipment needed to maintain their maximum independence. Resident’s rooms and bathrooms have ceiling hoists and there are two portable hoists available. Adjustable beds and pressure relieving equipments is also available for residents. Care notes give evidence that residents have access to specialist medical services as needed, and that they are supported to attend hospital appointments where relatives are unable to do this. An optician, dentist and chiropodist visit the home and are available as required. There are medication policies and procedures in the home and medication administration records seen were well maintained. Medication charts contained personal details of each resident together with a photograph. Medicines are administered by the registered nurses and resident’s medication is regularly reviewed by the GP. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaint procedure is given to residents in a suitable format. Complaints are dealt with and acted upon in line with the home’s complaints procedure. Not all complaints are recorded appropriately. Policies and procedures, and training for staff on abuse are in place to ensure residents are protected from harm. Staff are aware of the actions needed in the event of an incident, allegation or suspicion of abuse within the home. EVIDENCE: The home has a complaints procedure that is in a suitable format for residents. The complaints log was seen and one complaint that had been received was not recorded in the log although the complaint had been investigated and dealt with following the correct procedures. The pre-inspection questionnaire showed that training for staff on abuse had been provided in the past twelve months. Policies and procedures were in place for the protection of vulnerable adults. Staff spoken with were fully aware of their individual responsibilities in immediately reporting any incidents, allegations or suspicions of abuse within the home. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 17 Systems were in place to enable residents to access their own money when required and to protect them from any financial abuse. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, clean and comfortable home. EVIDENCE: The home is purpose built and resident’s rooms meet their individual needs and equipment available promotes their independence. Rooms are an adequate size to accommodate wheelchairs. Resident’s rooms are decorated when needed and residents are able to choose the colour scheme. The home has adequate bathroom facilities, and furnishings and fittings are of good quality. On touring the premises it was clean and fresh throughout. Sufficient domestic staff are employed to maintain the cleanliness of the home although no domestic staff work over the weekend period. The home has purchased an industrial carpet cleaner since the last inspection. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 19 The home has an on-going maintenance programme and the bathroom and shower room in the west wing had been re-tiled since the last inspection. The laundry facilities are suitable to meet the needs and numbers of residents. The care staff are responsible for the laundry. Policies and procedures are in place for infection control and staff were seen wearing protective apron and gloves as required. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. (excellent, good, adequate or poor) This judgement has been made using available evidence including a visit to this service. Residents are supported and cared for by competent, supervised and trained staff. Staff rosters show that there are a sufficient numbers of staff working to meet the needs of residents. The recruitment procedures and practices within the home ensure the residents are protected from harm. EVIDENCE: Staff rosters show that there is two registered nurses plus seven care staff working during the day and one registered nurse plus three care staff at night. An extra member of care staff works between 2pm and 10pm. Staff spoken with felt the staffing numbers were sufficient to enable them to provide the residents with the care they needed. All new members of staff undertake a twelve-week induction programme and Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 21 Sussex Healthcare has an extensive training programme that includes mandatory and specialist training. Staff are encouraged and supported to attend training courses of their choice. Individual staff training records show that seven care staff have achieved a National Vocational Qualification (NVQ). Three staff files were checked for recruitment procedures and two files showed that all the relevant checks had been carried out prior to staff working in the home. One file showed a member of staff had a Protection of Vulnerable Adults (POVA) check confirmed three days after starting to work in the home. However it was confirmed that new staff commence induction training and are supervised at all times. References for two members of staff recruited from overseas were obtained from employees within the Sussex Health Care Group. The registered manager confirmed that references from their previous employer were applied for but not received. Staff have formal staff supervision every two months that includes observations of work practice. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is well run and managed by an experienced and competent manager. Residents and relatives views about the home are obtained via satisfaction surveys and by regular contact with the registered manager. The home’s written policies and procedures and practices ensure the health and safety and welfare of residents and staff is protected as far as practicable. Systems and equipment in the home are serviced and maintained regularly. EVIDENCE: Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 23 The registered manager Eunice Mundopa is qualified and experienced to manage and run the home. Staff spoken with felt they were included in the decision making within the home and their views were listened to and acted upon. Sussex Healthcare has a quality assurance system in place that involves surveys being sent out to residents and relatives. Surveys are sent out at random every three months from the head office of the organisation. An audit of the results from surveys is completed and any actions needed as a result of feedback are acted upon. The last surveys were sent out in September 2006 It was recommended that surveys be sent to other health professionals for their view on the services provided by the home. The registered manager has an open-door style of management that enables residents and relatives to express their views on the home on a daily basis. The pre-inspection questionnaire shows that policies and procedures are in place for health and safety, and all equipment and systems are regularly maintained and serviced. All accidents and incidents are recorded and reported to the appropriate authorities. All accidents are recorded however minor. There have been no serious injuries recorded in the past twelve months. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 24 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 3 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 2 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 X 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 3 3 X X 3 X Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 25 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. 1 Refer to Standard YA22 Good Practice Recommendations All complaints received must be recorded giving the nature of the complaint, investigations, actions and outcome. Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 26 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 Kingsmead Lodge DS0000024164.V331470.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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