Inspection on 02/08/05 for Kearsney Manor Nursing Home

This inspection was carried out on 2nd August 2005.

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

Kearsney Manor Nursing Home 10/04/07

Kearsney Manor Nursing Home 15/11/05

Kearsney Manor Nursing Home 10/03/05

Kearsney Manor Nursing Home 12/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Kearsney Manor Nursing Home Alkham Road Kearsney, Dove Kent CT16 3EQ Lead Inspector June Davies Unannounced 2 August 2005 nd 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kearsney Manor Nursing Home Address Kearsney Manor, Alkham Road, Kearsney, Dover, Kent CT16 3EQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01304 822135 01304 829232 kmnh@btinternet.com Sisters of the Christian Retreat Mrs karen Jane Wilczek Registered Care Home 44 Category(ies) of Older Persons registration, with number of places Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10/03/05 Brief Description of the Service: Kearsney Manor Nursing Home is a large traditional stone building that has been extended; it is surrounded by extensive landscaped gardens, with a lake and established trees in addition there is a well tended vegetable garden, that produces fresh seasonal vegetables for the home’s kitchen. The home provides residential and nursing care for 44 older people, four of these beds are also registered to provide palliative care.The Home is close to Kearsney train station and buses run along the main road, a bus stop is situated close to the home. Pedestrians must take care, as the main entrance to Kearsney Manor is situated on the busy Alkham Valley Road Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection to Kearsney Manor Nursing Home carried out over six hours. The inspector gained evidence from the residents, staff and visitors to the home, and from observation during a tour of the building. What the service does well: What has improved since the last inspection? What they could do better: Some comments that were made by the residents that some of the care staff in the home, do not communicate with them while carrying out care tasks, and always appear to be in a rush, the residents then feel that they are a burden. The inspector noted that personal care carried out to the residents was not recorded in the care plan. One resident and a visitor said that dental care was not consistent, but there was no evidence to prove that this had been carried out, although a qualified member of staff stated that dental care had been given to this resident, therefore the inspector has made a requirement that all personal care tasks are recorded, signed and dated by the member of staff responsible. Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4, 5 Residents move into the home knowing that their needs can be met and that their independence will be maximised and promoted. Residents know that their goals and aspirations will be supported by the home. EVIDENCE: The inspector was able to view pre-admissions risk assessments for three of the homes newest residents. All three files contained holistic pre-admission information in regard to the residents’ history, health care needs and social needs. Also included with the pre-admission assessments were KCC care plans and hospital discharge assessment. The home has a multitude of aids to assist residents with mobility and sensory impairments. All assessed needs are written into the residents care plans. The home employs professionally qualified nurses and a good skill mix of care staff. Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 The care planning system is clear and consistent and provides staff with the information they need to meet the residents’ needs. The health needs of the residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The home needs to ensure that it meets all personal hygiene needs for the residents. The medication at this home is well managed promoting good health. EVIDENCE: The inspector was able to view five care plans all gave good written evidence of the physical and social care needs of the residents. Each care plan contained risk assessments for physical and social care. There was good evidence within each of the care plans that reviews are carried out on a regular basis. Care plans showed that the home regularly uses the expertise of external health care professionals and follow up reports are also written into the daily report sheets. The inspector could not find evidence of what personal care tasks had been carried out. During a conversation with one resident and their visitor, it was reported to the inspector that staff overlook dental care, on investigation there was nothing written into the care plan, that dental care had taken place, although the inspector was assured by a registered nurse that in fact dental care had taken place. The inspector has Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 10 made a requirement that all personal care tasks are recorded, dated and initialled by the staff member carrying out the task. None of the residents in the home are self-medicating. An inspection was carried out of the medication room and medication trolley. All MAR sheets were correctly filled in and signed, medication tallied with the MAR sheets, returned drugs were well recorded. The home has obtained from their clinical waste supplier the appropriate boxes to dispose of unused medication. The stock cupboard had appropriate stored medication all of which was in date. The management of controlled drugs was good, with clear recording and signatures in the controlled drugs book. Controlled drugs tallied with numbers recorded in the controlled drugs book. The inspector noted that policies and procedures for medication were clearly written, and easy to follow. A full history of medication is kept for each resident on the care plan. The inspector was able to visit and speak with twelve residents, some of these residents had visitors with them. All residents told the inspector how kind and caring the registered nurses were to them, and this was, reiterated by the visitors. Some of the residents said that there were good and bad care staff in the home, on exploring this further, the inspector was told, that some care staff give the impression that they really care, while others do not even bother to talk and always give the impression of being too busy to pass the time of day. The residents said that all staff respected their privacy and dignity, and when carrying out personal care would ensure that they shut doors and pulled curtains. Residents said that they were able to see their G.P’s in the privacy of their own bedrooms. Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15 Activities and community links are good and support the residents social opportunities. The meals in the home are good offering both choice and variety and catering for special diets. EVIDENCE: The home employs an activities co-ordinator and a physiotherapist. Activities are available on most days for the residents. Some residents join in the activities, which they said they enjoyed very much. In some cases residents are too frail, and spend most of their time in bed. Four residents told the inspector they did not wish to take part in activities, and were happy just to have visitors come to see them. Two residents said that they liked to spend time by the lake when the weather was good. During the summer months the activities co-ordinator tries to arrange outings for some of the residents. The residents are able to follow their own religious denominations, and there are regular visits from Roman Catholic and Church of England priests. Visitors are always welcome in the home, and this was evident on the day of the inspector’s visit. The residents spoke highly of the food they were offered in the home, all said they were able to have a choice, if there was food they did not like. Residents said that they were offered three meals per day, and drinks and snacks were available to them. Where food needs to be liquidised, the cook makes sure that this is done in the most appealing way. The inspector was present in the Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 12 home at lunch time, and observed that lunch looked appetising, appealing, and there were choices available to the residents. The home also has its own kitchen garden, where the gardener grows a range of seasonal vegetables. Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Residents and visitors know their complaints will be listened to and acted on. Staff have knowledge and understanding of Adult protection issues which protects the residents from abuse. EVIDENCE: No complaints have been received since the last inspection. The complaints policy and procedure is posted in the main entrance hall. One visitor said that she had made a complaint some time ago and that this was dealt with efficiently and within the timescale set out in the policy and procedure and that feed back was good. The home has recently received the revised edition of Kent County Council’s, Protection of Vulnerable Adults, the home also has its own adult protection policies and procedures. The deputy manager is qualified to train the staff, and runs adult protection training sessions for the staff, and evidence of this was available on the staff training matrix, which is displayed on a board outside the manager’s office. Members of staff spoken to were aware of the whistle blowing policy and procedure, and would not hesitate in reporting any suspicion of abuse to a resident. Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 26 The standard of the environment within the home is good providing the residents with an attractive and homely place to live. Laundry facilities are excellent, with detailed care being given to residents personal clothing. EVIDENCE: The location and layout of the home is suitable for its stated purpose. The home is accessible and well maintained. A new shaft lift has been fitted in the home since the last inspection. There is a programme of routine maintenance and renewal of fabric and decoration, and this was evident from walking around the building. The grounds are well tended, with brightly coloured flower beds, level pathways and seating around the lake. Two residents said how much they enjoy sitting by the lake when the weather is nice. The building complies with requirements of the environmental health officer, who has awarded the kitchen a clean food certificate, a letter is also available to show that the home complies with the requirements of the fire safety officer. The home was seen to have a high standard of cleanliness, and was free from offensive odours. Most of the staff have completed infection control training, and this was evidenced through conversation and the training matrix. A tour Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 15 of the building showed that clinical waste was being disposed of appropriately and that staff were issued with protective clothing and gloves. The laundry facilities are situated in a building away from the home. The inspector was able to view the laundry, which has exceptional standards of cleanliness and tidiness. All the residents clothing is meticulously ironed. The washing machines in the laundry comply with the washing standards to ensure that all laundry is thoroughly cleaned and there is no risk of cross infection. Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Staff morale is good, especially from the qualified staff, who offer the residents a high standard of care. Recruitment practices are excellent with all appropriate checks and training being carried out, which creates safety for the residents in the home. EVIDENCE: The inspector was shown the staff rotas, and these clearly showed that the home has sufficient staff on duty throughout each shift to meet the assessed needs of the residents at all times. There was also evidence of this on the day of the visit, with a registered nurse on each floor, for the two, day shifts and four care staff on each floor for the a.m. shift, reduced to three care staff on each floor for the late shift. There was also evidence on the day of the visit that there was a sufficient skill mix of staff to meet the assessed needs of the residents. The inspector spoke to registered nurses on duty and all agreed that there were sufficient staffing levels in the home, occasionally the work load gets heavy, when there are several residents ill at the same time. The inspector was able to view the three personnel files of the newest members of staff. Personnel files were excellently presented, with each file being sectioned off which made for easy inspection and clarification, there was also a check list at the front of each file to ensure that all paperwork was available within the file. The inspector was able to ascertain that POVA first checks had been completed, CRB checks were in place, all files had two written references one reference being from the previous employer, all staff had contracts of employment, and all staff had been issued with GSCC code of Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 17 conduct, each file contained training certificates, and there was evidence of induction taking place, together with staff supervision and appraisal. The majority of staff had undertaken mandatory training, with mop up training sessions organised in the near future for those staff who needed to update their certificates and for new members of staff, this was evidenced via the training matrix. There was evidence both from the training matrix and from conversation with staff members the training is ongoing and work related. Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 38 The manager is supported well by the senior staff in providing clear leadership throughout the home with the majority of staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The registered manager is qualified, competent and experienced to run the home. The registered manager is a qualified nurse and has also recently attained the NVQ level 4 and RMA qualification. On the day of the visit the manager spent time on the floor talking to the residents and staff. The manager’s office and all paperwork in the home is very well managed. Staff, residents and visitors all spoke very highly of the manager and her managerial skills. The manager discussed with the inspector her lines of accountability with the trustees of the home. The manager is very aware of health and safety issues in the home, and ensures through policies and procedures together with staff training that the Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 19 home has safe working practices. The majority of staff have completed their mandatory training, and for those who need to renew certificates or who are newly recruited further training sessions have been organised in the near future. The inspector was able to witness up to date maintenance certificates for all equipment used in the home including electrical circuit testing and gas appliance testing. There was evidence within the environmental risk assessment file that the building has regular risk assessments carried out. All fire call points and emergency lighting is checked and signed off on a regular weekly and monthly basis. There is an emergency plan for staff and residents, and a separate emergency plan for visitors to the building. The accident book complies with HSE guidelines, and showed there had been 30 resident falls since January 2005, the manager also keeps a falls matrix. The induction process in the home has changed since the last inspection and meets the National Training Organisation guidelines, evidence was available to show that all newly recruited staff have induction training. Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 4 STAFFING Standard No Score 27 3 28 x 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x x 3 Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 21 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. 1. Standard 8 Regulation 12 Requirement Care staff need to record all aspects of personal care to include, oral care, hair care, nail care, bathing etc. This record must be dated and signed. Timescale for action 1/09/05 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 Good Practice Recommendations Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford, Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kearsney Manor Nursing Home H56-H05 S26102 Kearsney Manor Nursing Home V233785 020805 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!