Inspection on 10/06/05 for Keldgate Manor

This inspection was carried out on 10th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Keldgate Manor 01/09/09

Keldgate Manor 06/09/07

Keldgate Manor 17/02/06

Keldgate Manor 25/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Keldgate Manor Keldgate Beverley East Yorkshire HU17 8HU Lead Inspector Diane Wilkinson Unannounced 10 June 2005 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. Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Keldgate Manor Address Keldgate Beverley East Yorkshire HU17 8HU 01482 882418 01482 882098 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) Mr David Raper Keldgate Manor Estates Limited Mrs Cecilia Raper Care Home 35 Category(ies) of OP Old Age (35) registration, with number DE(E) Dementia - over 65 (35) of places Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection December 2004 Brief Description of the Service: Keldgate Manor is a care home that is run by a privately owned family business. The home is an eighteenth century property that has been adapted and extended to provide accommodation and care for 35 older people, including those with dementia. It is situated in the market town of Beverley. The home stands in an acre of land that has mature trees, flowerbeds and a large ornamental pond. Accommodation is located over three floors - communal accommodation is provided in two quiet lounges, a large lounge and dining room/lounge at the rear of the building - the two latter rooms overlook the large garden. Individual accommodation is provided in 23 single rooms and six double rooms. Car parking space is available at the rear of the property, and the home is close to the town centre and is easily accessed via road. Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 8 hours, including one hour’s preparation time prior to the inspection. The inspection included a tour of the premises and examination of relevant documentation, including care plans. The inspector spoke to several service users, members of staff and the registered manager. What the service does well: What has improved since the last inspection? What they could do better: Equipment used by service users must be maintained consistently. A daily menu should be displayed to encourage independence and to inform relatives of the meals on offer at the home. Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_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. Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_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 Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_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 Service user’s needs are assessed prior to admission to ensure that their care needs can be met and that the home is an appropriate placement for the service user. EVIDENCE: The inspector examined care plans for 5 service users. One of these service users had been admitted to the home three days earlier as an emergency admission. The social worker had visited the home to inform staff about the needs of the service user and two staff had gone to the service user’s home to bring them in to Keldgate Manor. The registered manager said that, at this stage, they would not have brought the service user into the home if they had felt that the service user’s needs could not be met. On this occasion it was decided that the home would be able to meet the service users needs and an eight-week respite stay was agreed to. A care plan has not yet been received from care management, but the home has started to undertake it’s own assessment and a care plan has been developed. A GP has visited this service user and very detailed notes had been made of this visit. Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 9 The registered manager informed the inspector that, under normal circumstances, service users are visited at home or in hospital prior to any decision being made about admission to the home, and the assessment process starts at this stage. Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 10 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 and 8 A thorough care plan ensures that a service user’s care needs are identified. Recording and discussion evidences that identified care needs are met by staff at the home. EVIDENCE: The care plans examined by the inspector included a detailed care plan that records how a service user’s care needs should be met by staff. There is a thorough risk assessment in place and this is updated monthly, along with any changes that need to be made to the care plan. The inspector observed that care plans have been updated appropriately, for example, changes in medication or commencement of visits from a district nurse. Formal reviews are held and these are attended by service users whenever possible. Service users informed the inspector that they are aware that there is a care plan in place, and the residents questionnaire asks service users this question. Completed questionnaires seen by the inspector all recorded that service users are aware of the existence of a care plan. Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 11 Care plans and discussion with service users evidence that care needs are met. Records include a ‘self care’ checklist. Pressure care is recorded appropriately and suitable equipment to prevent pressure sores developing or worsening is provided for service users. Separate records are kept of visits by GP’s and District Nurses and the outcome of these visits are recorded. Nutritional screening takes place. Following an outbreak of influenza at the home that left some service users debilitated, the registered manager had introduced two extra drinks per day for service users, at 11.00 am and 4.00 pm. Fluid intake and output is recorded on the recommendations of a GP or if this is an area of concern for staff. Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 12 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) 14 and 15 Service users are supported and encouraged to exercise choice and control over their lives. The meals in the home are good offering both choice and variety and catering for special dietary needs. A daily menu is not displayed and this could result in service users not being aware of the full range of meals on offer. EVIDENCE: The inspector discussed choice and control with several service users. All confirmed that they can choose what time to get up and go to bed, where and how to spend the day, where to take their meals and to join in activities if they wish to do so. A ‘lifestyle’ audit tool is used to record a service user’s wishes including times to get up and go to bed, spiritual needs and any special dietary requirements. There is a record of a service user’s personal history, family contacts and previous hobbies and interests. Evidence suggests that service users are encouraged and supported to maintain interests that they had prior to their admission to the home. There is a six-week menu in operation and this includes a three-course meal each lunchtime. Service users are informed of choices for meals ‘on the day’ – the inspector recommends that a menu is displayed to encourage Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 13 independence for service users and to ensure that they are fully aware of the available choices, and to inform relatives of the meals on offer at the home. The inspector observed lunch being served in the conservatory/dining room. One service user said to staff ‘This is nice soup – it has a bit of a tang to it’. On the day of the inspection the choice of meal was fish and chips or egg and chips. Many service users chose egg and chips and the cook quickly prepared more eggs to meet the requests of service users. Service users were asked if they would like a second helping. One service user asked for fruit instead of the desserts on offer and this was provided. Various choices are offered at tea-time – this was confirmed in discussion with service users. The meal was unhurried and staff were seen to assist service users appropriately. Special diets are catered for, for example, diabetic and low salt diets. There are ample drinks provided throughout the day. Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 14 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 and 18 The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. Service users are protected from abuse by robust systems and policies and procedures that are understood by staff. EVIDENCE: The home’s complaints procedure is displayed on the notice board. The inspector examined the complaints log – one complaint was recorded in August 2004 and this had been dealt with and recorded appropriately. The registered manager met with the complainant, and the complaint was discussed at the next staff meeting to ensure that all staff were aware of the details and outcome of the complaint. Service users spoken to said that they know how to complain about the service provided by the home and would do so if they felt it to be necessary. In 2004 a vulnerable adults allegation was made by a service user’s family. This allegation was investigated by the Social Services Department of the local authority and the report fully exonerated staff at the home. The deputy manager has attended vulnerable adults ‘Manager’s Awareness’ training and is now cascading training to all staff. There are various policies and procedures in place to protect service users from abuse, such as whistle blowing, handling resident’s monies, bullying and abuse/aggression. These polices and procedures have been signed by staff to evidence that they have Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 15 read and understood them. Any concerns about individual service users would be discussed at team leader meetings and monthly staff meetings to ensure that there is a consistency of approach in dealing with specific behaviours presented by service users. Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 16 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 The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: All areas of the building are accessible via the provision of a passenger lift, a stair lift and ramps. The grounds are tidy, safe and very attractive and are accessible to service users from various exits at the rear of the property. A programme of maintenance is included in the annual development plan and the home presented as being well maintained on the day of the inspection. Mobility equipment such as mobility hoists and bath hoists are provided, and grab rails are provided in communal and private areas of the home. Furnishings and décor are comfortable and homely. Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 17 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 and 30 The staff rota evidences that there are sufficient skilled staff on duty to offer consistency of care within the home. Dedicated catering and domestic staff ensure that hygiene standards are maintained and reduce the risk of cross infection. Individual training records evidence that staff have the knowledge to carry out their role effectively, but a specific training and development programme would enhance training records by detailing the strengths and needs of the staff group as a whole. EVIDENCE: The staff rota records the staff who are on duty each day, and the role in which they are employed. There is a mix of long-standing staff and newer staff employed at the home, and training records evidence that staff have the skills to enable them to meet service user’s needs. There are additional staff on duty at peak times of the day and evidence indicates that sufficient day and night care staff are employed. The number of domestic staff employed ensures that the premises are kept in a clean and hygienic state, and dedicated catering staff are employed to provide meals, snacks and drinks. The family live on the premises and someone is always available in the event of an emergency. The inspector examined individual training records for some of the staff employed at the home. Staff undergo a thorough induction process and have an annual appraisal, when their training needs are discussed. The annual Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 18 development plan includes some details of training undertaken during the year, and plans for the forthcoming year. The inspector recommends that a specific training and development programme should be developed that meets National Training Organisation workforce training targets and records the strengths and needs of the whole staff group. This would evidence that staff can meet the changing needs of service users. NVQ training is ongoing. Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 19 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) 38 There are systems in place to ensure that the health, safety and welfare of service users is protected and promoted. Some equipment at the home had not been serviced recently and this could place service users at risk from injury. EVIDENCE: There is evidence that health and safety training takes place on an on-going basis. A written statement of the policy, organisation and arrangements for maintaining safe working practices is provided. The fire alarm system has been tested by a qualified contractor and in-house tests of the fire alarm system take place. There is a gas safety certificate in place and staff undertake a portable appliance test on all electrical appliances (using their own equipment that has recently been recalibrated). The Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 20 passenger lift and stair lift have been serviced recently. Water temperatures are tested each time a service user has a bath, but the inspector recommends that water temperatures should be tested in bathrooms and bedrooms to control the risk of scalding, and that the outcome of these tests should be recorded. Accidents are recorded appropriately and these are monitored to identify any patterns with service users, care practices or the premises. The bath hoists and mobility hoists had not been serviced since April 2004. On making further enquiries the provider was informed that the company used by the home has gone out of business so alternative arrangements had to be made to maintain this equipment. This work has since been arranged for the 5th July. Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 21 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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 x 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 x x x x x x x 1 Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 22 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 38 Regulation 23 Requirement Bath hoists and mobility equipment must be serviced on a regular basis. Timescale for action 5.7.05 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. 2. 3. Refer to Standard 15 30 38 Good Practice Recommendations The inspector recommends that a daily menu is displayed. The inspector recommends that a specific training and development programme is developed. The inspector recommends that water temperatures in bathrooms and bedrooms are tested to control the risk of scalding, and that the outcome of these tests are recorded. Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Keldgate Manor J53_s19685_Keldgate Manor_v228612_100605_Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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