Inspection on 16/04/07 for Ernest Kleinwort Court

This inspection was carried out on 16th April 2007.

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 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

Ernest Kleinwort Court 11/01/06

Ernest Kleinwort Court 06/07/05

Ernest Kleinwort Court 24/11/04

Ernest Kleinwort Court 30/06/04

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOME ADULTS 18-65 Ernest Kleinwort Court Oakenfield Burgess Hill West Sussex RH15 8SJ Lead Inspector Mrs M McCourt Unannounced Inspection 16th April 2007 09:00 Ernest Kleinwort Court DS0000014501.V337182.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 Ernest Kleinwort Court DS0000014501.V337182.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. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ernest Kleinwort Court Address Oakenfield Burgess Hill West Sussex RH15 8SJ 01444 247892 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) philipmazy@aol.com The Disabilities Trust Mrs Marilyn Muriel Freeman Care Home 35 Category(ies) of Physical disability (35), Physical disability over registration, with number 65 years of age (35) of places Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 2006 Brief Description of the Service: Ernest Kleinwort Court is a care establishment registered to provide accommodation and personal care for a maximum of thirty-five people who are physically disabled between the ages of eighteen and sixty-five years. The registration also makes provision for those who are over the age of sixty-five years to enable residents to remain in the establishment until the end of their lives if they wish, and if it is appropriate for them to do so. The registered provider is The Disabilities Trust, which is a voluntary organisation. The responsible person for the organisation is Mr P Pilbeam and the registered manager is Mrs Marilyn Freeman who is responsible for the day-to-day running of the home. The purpose built single storey building is located on the outskirts of Burgess Hill town, close to shops and local amenities. It provides spacious personal living accommodation with en-suite facilities and a range of communal rooms, all of which are specifically designed to accommodate and facilitate residents with physical disabilities. In addition, there is a small unit of independent single flats situated in the level garden to the rear of the main building and two adjacent bungalows, which form part of the registered accommodation. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection was undertaken by one Inspector on Monday 16th April 2007 and lasted a total of eight hours. Pre-inspection planning took approximately three days, consisting of the review of previous inspection reports, reading of the pre-inspection questionnaire and all of the preinspection documents requested. In addition, the inspector examined information received from other relevant professional bodies and regulatory information received by the Commission of Social Care Inspection (CSCI). A full tour of the building took place and included the observation of health and safety matters, hygiene issues, decorative order and a general overview of the atmosphere created within the home. Five staff members and the registered manager were spoken to at the time of inspection. Case tracking was carried out by examination of relevant records and information held on the staff and residents. The Inspector also spoke with four Service Users accommodated at the home. Policies and procedures were examined during the site visit. The Commission has received two complaints in respect of the service and these have been documented within the main body of the report. Weekly fees range between £850 and £1300 per week. This information was obtained from pre-inspection material. What the service does well: The home is unique, in that there are different styles of accommodation provided over the complex. The abilities of service users is wide ranging, with the home providing tailor-made care packages, with some people receiving one-to-one support from the independent living team, which enables them help with various tasks, including; paying bills, cooking, buying personal shopping and so on. Complete care programmes are provided by the home, with one staff member being responsible for assisting one person to get up, washed, dressed, right through to eating breakfast, providing a consistent approach. Service users confirmed that they are able to choose from a good range of suitable activities and are encouraged to pursue any specific interests and hobbies they may have, both within and external to the establishment. The Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 6 inspector was of the opinion that the list of events, planned for the forthcoming year, would be both entertaining and meaningful. Service users have constant access to light refreshments, with hot and cold drinks machines available in the dining room and a fully stocked salad bar. The choice and quality of the food on offer is excellent and the catering manager works hard to ensure that everyone is catered for. Communal space is plentiful and a great deal of thought has gone into ensuring service users are able to access all areas. For example, a ‘red’ kitchen, purpose built, has a designated domestic area where service users can cook or bake with support from staff. All the surfaces have been lowered, including the sink, cooking rings and so on. In addition service users can do their own laundry and/or keep food items in the fridges provided. 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. Ernest Kleinwort Court DS0000014501.V337182.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 Ernest Kleinwort Court DS0000014501.V337182.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 and 5. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has a thorough and comprehensive assessment process in place, with all care needs carefully considered prior to admission. Contracts are in place and all signed and dated by both the service user and the home. EVIDENCE: Prospective service users are invited to an initial visit to view the home, where they received lunch if they wish, following which an assessment of need is carried out by the registered manager. When it has been decided whether the home can accommodate the person, fees are set, on an individual basis. Once approved and admitted into the home, the manager writes a basic care assessment that is reviewed after several weeks, the end result being a tailored care programme. This includes; personal care, moving & handling, diet, communication, mobility, skills and so on. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 9 Contracts are in place and have been signed by both parties. However, some need to be dated. The contract details fees charged and breach of contract information. Ernest Kleinwort Court DS0000014501.V337182.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): 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. Service users know that their assessed and changing needs are reflected in their individual plan. Service users are supported to take risks as part of an independent lifestyle and are encouraged by staff to make their own decisions. EVIDENCE: Care plans are reviewed twice each year, with the home arranging an official review, to which health professionals, relatives and so on are invited annually. In addition, the home carries out another review of the plan, approximately six months after the official review. The home does not use advocacy services at present, but the home has used local advocacy groups in the past, for specific issues. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 11 Risk assessments are in place and are reviewed regularly. The risk assessments are identified and fully discussed prior to implementing and are written up and placed on individual files. Generic risks are also identified and stored in a separate filing system. Discussion with service users demonstrated that meaningful activities do take place and any associated risks identified are documented. One service user told the inspector that she is able to travel into town unaccompanied. One day per week she also works in a local school, listening to children read, which she really enjoys. Another service user has her own personal computer, with webcam and adapted for her physical needs. She uses it to talk to her friend in New Zealand, which she does frequently. Service users supported by the independent living team are able to take advantage of one-to-one assistance, which enables them help with various tasks, including; paying bills, cooking, buying personal shopping and so on. Ernest Kleinwort Court DS0000014501.V337182.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): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users do have access, and take part in, appropriate activities and are visible within the community. The home provides an exceptional catering service, with services users having an extensive choice at meal times. The catering manager and staff ensure that meals are varied, nutritional and balanced. EVIDENCE: The home is unique, in that there are different styles of accommodation provided over the complex. The abilities of service users is wide ranging, with the home providing tailor-made care packages. For example, people who live in the lodge need less care support, than those who live in the flats. Some people have ‘independent living’ staff who work with them on a one to one Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 13 basis as well as in groups. This enables some service users to be accompanied when they go out or to receive help with specific tasks. Service users confirmed that they are able to choose from a good range of suitable activities and are encouraged to pursue any specific interests and hobbies they may have, both within and external to the establishment. A list of events planned for the forthcoming year is on display in the entrance hall. There is something taking place every month, including; singers/music evening, race night (betting on dog racing), summer fete/BBQ, glam rock night, and so on. One service user told the inspector “I am never ever bored, staff work well with me and treat me with dignity and respect. She said that the she can approach the manager about any concerns and feels listened to, and added that staff are very approachable too. Service users have access to various holiday information and brochures, from which they are able to choose a holiday that can cater for their abilities and where care is provided. One service user has recently returned from Spain and was escorted by an external agency. The inspector was told that the holidays have to be funded by the local authority, or privately, as the home does not make any provision for the cost of such holidays in its fees. The Commission for Social Care Inspection received a complaint, stating that the home does not include the cost of a holiday in its fees. On discussion with the registered manager the inspector was told that the Statement of Purpose and Service User Guide detail that holidays are not included. However, the inspector examined the documents and found that there was no reference to holidays. The home must make it clear in their Statement of Purpose and Service Users Guide what services and facilities are included in the fees charged. It was confirmed that service users are enabled to develop and maintain intimate personal relationships with people of their choice, information and specialist guidance are provided to help the service users to make appropriate decisions. Staff were observed by the inspector to knock before entering service users private accommodation. Locks were provided on all doors to service user’s rooms. Service users have constant access to light refreshments, with hot and cold drinks machines available in the dining room. A catering manager is employed, and she works with and has responsibility for four cooking Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 14 assistants. The catering manager said that she meets with residents about three times each year, at which time they put forward their requests for food. She will then write up a four-week menu. Changes to this are made when there is a specific reason, for example, if some service users go fruit picking, they may wish to cook using the fruit they have gathered, and include it in a meal, which the catering staff will accommodate. The home has purchased a large salad bar, which is kept fully stocked-up and is replenished twice a day. Compartments are stocked with health food options, such a; cheese, lettuce, peppers, prawns, cold meats, coleslaw, tomatoes and so on. In addition to the salad bar, service users are given a choice of three cooked meals at the main meal time, and two choices for the evening meal. The inspector sampled a meal on the day of inspection; chicken Kiev with fresh vegetables, and found it to be well presented and appetising. There is a licensed bar in the dining room, with the registered manager being a licensee. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 15 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 excellent. This judgement has been made using available evidence including a visit to this service. The service users physical and emotional needs are met by the staff team, with the home accessing specialist care as and when required. Medication is stored and administered appropriately. EVIDENCE: Complete care programmes are provided by the home, with one staff member being responsible for assisting one person to get up, washed, dressed, right through to eating breakfast, providing consistency. Records are written up using a cardex system. There is a multi-disciplinary section that records notes from neurological consultants, out patient visits, G.P.’s, physiotherapists, district nurses and so on. A care diary is used to record all health appointments. Staff formulate the following days work plan and the senior carer then allocating duties amongst the team on each day. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 16 There is no designated keyworker system in place, but if a particular project or need is identified, a member of staff is designated to support the service user throughout the process. Service users spoken with said that they can bring any problems or issues they have to their personal care reviews, or if they are general problems, these can be discussed in the residents meeting. One service user said that they believe to be “well treated” and said, “it is better than at my previous home”. They went on to say that they could go to bed and get up whenever they choose. Medication is stored in a large cupboard, located in the treatment room. Stock was neatly stored. Risk assessments were in place for those who self-medicate - they have a form (like a MAR sheet) that they sign when they self-administer, which is returned to the Care Services Coordinator each month. If service users cant sign, staff will sign on their behalf. MAR sheets looked at were up-to-date and accurate. Controlled drugs storage and recording were examined and found to be up-todate and accurate also. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. The home should review the way in which complaints and/or concerns are recorded, and all complaints, regardless of how minor should be logged. Staff have still to attend appropriate training in adult abuse issues. EVIDENCE: A complaints log is available, but there have been no entries since 2005. The inspector spoke with the registered manager around ensuring that all concerns and complaints are recorded. During the course of the inspection, a service user had made a complaint about a misunderstanding between themselves and care staff. In addition, the commission had received two separate complaints, none of which had been recorded anywhere in the home’s own log, even though the organisation had responded to one of the complainants in writing. A service user told the inspector that they would like to have their room dusted more often, as at the moment it is just vacuumed once a week. Currently it is dusted about once each month, but they believe that this is not often enough and said that other service users felt the same way. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 18 The West Sussex County Council’s adult abuse procedures file is available at the home. However, staff have not yet received any form of adult abuse training, and the inspector considered this to be a concern, particularly with regard to the client group cared for. The registered manager said that the adult abuse programme for staff training only started rolling out last year. All staff will eventually be booked onto it. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 19 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, 26, 27, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable and well-maintained environment, with accommodation tailored to suit individual need. The home is hygienically clean with no unpleasant odours detectable. EVIDENCE: The property is located within a cul de sac in a quiet residential area of Burgess Hill. The accommodation for service users is spread over a large site and includes flats, lodges, two bungalows and the main home itself. Doors to the main entrance are automatic and wide for ease of access. The large reception area consists of a reception office, care office and the managers office. A telephone kiosk is available for making personal calls, although some of the service users have their own personal phones. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 20 There is a treatment room, used for various medical treatments, such as; physiotherapy, chiropody and so on. Service users have access to bathrooms with assisted equipment to enable people with physical disabilities to bathe. There are also walk in showers and two designated kitchen areas have lowered work surfaces, for ease of access. Bedrooms in the main part of the building are bed-sit in style, with en suite bathrooms and a large, built-in cupboard area (for bed-linen, towels, etc). Specialist equipment was observed to be in place, for example; ceiling track hoists. Individual rooms have been decorated to suit individual taste, and the inspector saw a room being redecorated and redesigned for a service users specific needs. Communal space is plentiful and includes; a breakfast kitchen, for use if people prefer privacy when eating, rather than joining others in the main dining room. A ‘red’ kitchen, which is purpose built, with a designated domestic area where service users can cook or bake with support from staff. All the surfaces have been lowered, including the sink, cooking rings and so on. In addition service users can do their own laundry and/or keep food items in the fridges provided. In addition the main kitchen is of an industrial size with industrial appliances. A catering manager is employed and is responsible for four assistant cooks. The chef keeps a record of food cooked and does not allow any food cooked outside of this kitchen to be reheated or served from it. Patio doors lead from the small kitchen, through to communal gardens, consisting of; seating/patio areas, grass lawns, a bird aviary, greenhouse and a begola with climbing wisteria. On the day of inspection there was a member of staff picking out seedlings to grow in time for the home’s ‘fun-day’ in August. Money raised goes towards on-going projects within the home. The sitting room/dining room is a very large room with designated areas. One area has many large, comfy chairs around a large, pull-down screen (used for race nights), and at the opposite end there are facilities for making light refreshments with the use of hot and cold drinks machines and small kitchenette. Nearby is a salad bar that is kept fully stocked (replenished twice a day) which includes 30 different storage compartments (lettuce, peppers, prawns, cold meats, coleslaw, tomatoes, cheese and so on). Down a corridor to the left of the kitchen are six flatlets, each one consisting of kitchenette, bed-sitting room and en suite bathroom or shower (depending on preference). Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 21 At the rear of the property there is a large activity building where people can paint, pottery, arts, crafts, use a computer and so on. There are seven lodges, similar in style to the self-contained flats, with a sitting/bedroom, kitchen area with purpose built, lowered work surfaces and appliances, and shower rooms with assisted equipment where required. Each of these lodges is set up to serve individual needs. The complex also incorporates two bungalows, purpose built for wheelchair access. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 22 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): 31, 32, 34, 35 and 36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported by appropriate numbers of staff. Staff are competent and well trained in their roles. The home has a good level of commitment to recruitment procedures, ensuring the safety and protection of service users. EVIDENCE: There are 81 staff employed and this number includes ancillary staff, estates staff, laundry staff, housekeeping staff, catering staff, administration staff, an independent living team of staff (who focus on 1 to 1 support to achieve set goals and develop skills) and support workers. Eight staff work an early shift, with five working evenings, three on waking night and a twilight shift (9pm to 1am) to help with the evening routine. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 23 Support workers are on a rolling programme for NVQ. The ‘Trust’ has set up its own NVQ course, with qualified assessors in place, and approximately 45 of staff have at least NVQ level 2. Mandatory training is also carried out on a rolling programme. Specific training of interest is also offered, such as; spinal cord injuries. The home has achieved the Investors in People award. Staff spoken with confirmed that they had received an induction and probation period when they commenced work with the organisation. Staff also said that they had received training in mandatory subjects, although not in adult abuse. Formal supervision does take place, approximately every four to six weeks, once staff have successfully completed their probation period. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 24 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, 38, 39 and 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a well run home that is managed to suit their best interests. The home has implemented a good quality assurance tool that enables service users and relatives to voice their ideas and/or concerns. The health, safety and welfare of service users and staff are promoted and protected by relevant policies and procedures. EVIDENCE: Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 25 Mrs Marilyn Freeman has managed the home for approximately four years, although has worked her way up at the establishment over the past 22 years. She originally started as a night support worker. She sees her role as more developing, maintaining and business planning now. She has completed NVQ level 4 and is currently studying for her RMA. Anonymous questionnaires are carried out bi-monthly and request different information each time. Results are then evaluated and sent to the ‘Quality Assurance Department’, at central support. Regulation 26’s are carried out on a monthly basis. Health and safety policies are in place and were up-to-date. Fire officers last visited the premises on 26.6.06 and an equipment check was carried out in January 2007. Fire drills and weekly testing of alarms are carried out regularly. In order to maintain good infection control practices, any person who has been discharged from hospital is automatically barrier nursed for two weeks, regardless of whether they are diagnosed with an infection or not. Staff spoken with said that the “manager and management of the home is good”, and that the manager was very supportive. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 26 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 4 3 X 4 X 5 4 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 4 28 4 29 4 30 4 STAFFING Standard No Score 31 4 32 4 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 4 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 4 4 3 X X 3 x Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 27 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 2 Refer to Standard Good Practice Recommendations The home must ensure that all complaints are followed up and documented appropriately, using a clear recording system. All staff require training in adult abuse issues, and this should be carried out as soon as is possible by the registered provider. Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 28 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 Ernest Kleinwort Court DS0000014501.V337182.R01.S.doc Version 5.2 Page 29 - 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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