Inspection on 17/02/06 for Keldgate Manor

This inspection was carried out on 17th February 2006.

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

Keldgate Manor 01/09/09

Keldgate Manor 06/09/07

Keldgate Manor 10/06/05

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 Inspection 17th February 2006 10:30 X10015.doc Version 1.40 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 Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 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 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 DS0000019685.V261640.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Keldgate Manor Address Keldgate Beverley East Yorkshire HU17 8HU 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) 01482 882418 01482 882098 Keldgate Manor Estates Limited Mrs Cecilia Raper Care Home 35 Category(ies) of Dementia - over 65 years of age (35), Old age, registration, with number not falling within any other category (35) of places Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th June 2005 Brief Description of the Service: Keldgate Manor is a care home that is operated 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 and is close to the town centre. 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 - the two latter rooms overlook the large garden. Individual accommodation is provided in 23 single rooms and six shared rooms. The home is easily accessed via road and car parking space is available at the rear of the property. Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by one inspector over a period of seven hours, including preparation time for the inspector. The inspection consisted of a tour of the premises and examination of documentation, including care plans. The inspector spoke with several service users, two relatives, the deputy manager and the registered manager. What the service does well: What has improved since the last inspection? What they could do better: Any activities undertaken by service users and any visitors seen/visits taken out of the home should be recorded in their care plan. Recruitment and selection practices must be more robust to protect service users from the potential to be abused. Monies held on behalf of service users must be in a bank account in the name of the service user(s). Water temperatures in hand washbasins in bedrooms and bathrooms must be regulated to control the risk of scalding for service users. Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 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 DS0000019685.V261640.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 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 the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 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 the following standard(s): 9 and 10 The systems for the administration of medication are good and protect the health and safety of service users. Service users report that privacy and dignity is respected at all times. EVIDENCE: There are appropriate policies and procedures in place regarding the administration of medication. Staff that administer medications have either undertaken accredited medications training or are currently undertaking this training. Medication records should include a list of the names of staff that are trained to administer medications and a sample of their signature - the registered manager agreed to compile a list. The storage of medication and the recording of administration are satisfactory. None of the current service users are prescribed controlled drugs but there is a storage facility and controlled drugs book available should this occur. The service user guide and contract state that service users will not administer their own medication, but add that ‘if this creates a problem, then please discuss this with the manager’. The inspector recommends that this statement Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 Page 10 be reconsidered to give more emphasis to the right of service users to self medicate should they wish to do so (within a risk management framework). Care plans include a list of current medication taken by service users and a record of any changes made to medication prescribed by medical practitioners. Service users informed the inspector that they are treated with respect and that their right to privacy is upheld. They are spoken to appropriately by staff and staff knock on their bedroom door before entering. Service users said that, when they are assisted with personal care, this is done sensitively. The inspector observed this on the day of the inspection. Care plans include a satisfaction survey and, in those seen by the inspector, service users had answered ‘yes’ to the question ‘Are you treated with dignity and respect by staff?’ There are private areas of the home where service users can meet with health professionals and visitors but visitors tend to remain in the lounge with service users. Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 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 the following standard(s): 12 and 13 Service users are supported and encouraged to maintain their chosen lifestyle following admission to the home. Friends and relatives are encouraged to visit the home and are made welcome. EVIDENCE: Care plans include a very detailed record of a person’s previous lifestyle, life history and hobbies and interests. The inspector observed that service users spend time reading and watching the television, and an area just outside one of the back doors has been nominated as the smoking area. A small group of service users usually sit together to have a cigarette. Care plans are quite comprehensive but the inspector noted that very little is recorded on a daily basis about the activities undertaken by service users and how they have spent their day. No activities programme was displayed in the home at the time of the inspection. A hairdresser visits the home every week and most service users access this facility. In the satisfaction survey previously mentioned, service users stated that they were happy with the activities on offer at the home. There are always visitors in the home when the inspector visits and it is evident that visitors are made welcome. A section in the care plan entitled Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 Page 12 ‘special notes’ includes details of such things as ‘seen by the dentist, visit from solicitor’, but does not record social visits by family and friends. Discussion with staff informed the inspector that service users are supported to go out of the home unassisted if this is felt to be safe. Visitors informed the inspector that they are able to visit the home whenever they wish to do so. Some service users are taken by family and friends to have visits out of the home. The inspector noted that a weekly menu is now displayed. Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 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 the following standard(s): None of these standards were assessed on this occasion. EVIDENCE: Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 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 the following standard(s): 26 Laundry facilities are satisfactory and the home is maintained to a clean and hygienic standard. EVIDENCE: Laundry facilities meet required standards and there is a separate sluice facility. There is a satisfactory infection control policy in place. The home employs dedicated domestic staff and catering staff and this reduces the risk of cross infection. Service users told the inspector that their clothing returns from the laundry in good condition and that any mislaid items are soon found. The home was clean and hygienic on the day of the inspection, with the exception of some slight odours in bedrooms. The inspector was confident that these are being dealt with appropriately. Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 Page 15 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 and 30 Recruitment policies and practices at the home do not currently ensure the safety of service users. Appropriate staff training takes place (including NVQ training). A training and development programme would evidence that staff training meets Skills for Care workforce targets. EVIDENCE: There are twelve care staff employed at the home. Five staff have achieved NVQ Level 3 in Care and five staff are undertaking NVQ Level 2 or 3 in Care. Two ancillary staff are also undertaking NVQ training. This will result in the requirement for 50 of care staff to achieve NVQ Level 2 in Care being met. The recruitment and selection records for a new member of staff were examined by the inspector. These evidence that an application form is used by the home that records the applicant’s previous experience and their current or most recent employment. This section of the application form should be expanded so that applicants can record their full employment history – the home will then be able to explore any gaps in employment. Records evidence that this person commenced work at the home before two written references and a POVA first check or satisfactory CRB check had been obtained. The registered person is reminded that, when a POVA first check is obtained, the employee must work under supervision until a satisfactory CRB check is received. Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 Page 16 Individual training records are held for each member of staff. Each new employee receives a pack containing details of their induction training, ongoing training and an individual training record. When staff have completed their induction training they are enrolled on an NVQ training programme. Fire training is held every six months and there is evidence that core training (including refresher training) is undertaken on health and safety topics. There is a no collated record of staff training achievements and staff training needs for the whole staff group. Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 Page 17 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The home is managed by an experienced and competent person. There is an effective quality monitoring system in place. Monies held on behalf of service users are held securely and accurate records are kept on monies paid in and out. These monies should only be held in accounts in the name of the service user(s). Current arrangements for safe working practices do not ensure that the health, welfare and safety of service users are protected. EVIDENCE: The registered manager is experienced, competent and qualified to run the home. She is a registered general nurse who has retained her registration with the Nursing and Midwifery Council. She has undertaken first line and middle line management training whilst working for the NHS and has achieved the NVQ assessor and internal verifier awards. There are clear lines of accountability within the home. Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 Page 18 The home has achieved the Investors in People award and QDS, the local authority quality scheme. There is a very detailed annual development plan in place. Staff meetings are held and staff are required to sign a document to evidence that they have read the minutes of the meeting. Service user meetings are held once monthly but the registered manager said that few service users attend. Service users (frequently assisted by relatives) complete a questionnaire prior to each review, including their initial review. This asks a wide variety of questions about the care provided by the home. The inspector recommends that the outcomes of these questionnaires are collated and published, and that other stakeholders are included in the quality monitoring process. The registered person summarises any complaints received by the home and this information is included in the quality monitoring system. A copy of the questionnaire is included in the home’s statement of purpose to inform service users that they are asked for their views about the quality of the service offered by the home. Monies held on behalf of service users and associated records were examined by the inspector. Monies are held securely and accounts are maintained that record money received and monies spent on behalf of service users. This is balanced at the end of the month, and a ‘running total’ is recorded. Money for one service user is paid into the private account of the registered manager. This is with the agreement of the service user, their relatives and care management. Other monies are paid into the company bank account, again, with the agreement of all parties concerned. This does not meet with Regulation 20 of the Care Homes Regulations 2001 that states “the registered person shall not pay money belonging to any service user into a bank account unless (a) the account is in the name of the service user, or any of the service users, to which the money belongs and (b) the account is not used by the registered person in connection with the carrying on or management of the care home”. The registered person is required to find alternative means for holding monies on behalf of service users. There is now evidence that bath hoists and mobility hoists are serviced regularly. Water temperatures are controlled by thermostatic valves in baths, but not in hand washbasins in bathroom or bedrooms. The inspector tested the water temperature in bedrooms in various areas of the building and these were all over 43°C. There must be controls in place to ensure that water at all outlets that are accessible to service users is distributed close to 43°C. Fire extinguishers were tested in September 2005, emergency lighting was tested in November 2005 and the fire alarm system was tested in November 2005 by qualified contractors. In-house fire tests are undertaken on a regular basis and there is a fire risk assessment in place. There is a gas safety record and a central heating maintenance plan in place. Portable appliance tests were undertaken between May and July 2005. The inspector saw evidence that the equipment used to undertake these tests had Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 Page 19 been calibrated. The stair lift and the passenger lift have been serviced and there is now evidence that bath hoists and mobility hoists are serviced regularly. Accidents are recorded appropriately. There is a written statement of the policy, organisation and arrangements for maintaining safe working practices, including appropriate risk assessments. Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 X 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 1 X X 1 Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 19 Timescale for action There must be a satisfactory CRB 17/02/06 check or POVA first check and two written references in place before staff commence work at the home. If a POVA first check is obtained, staff must work under supervision until a CRB check is received. The registered person is required 30/04/06 to find alternative means of holding monies on behalf of service users that meets Regulation 20 of the Care Homes Regulations 2001. Water temperatures must be 30/04/06 controlled to be close to 43° at outlets accessible to service users. These must be tested and recorded to evidence compliance. Requirement 2. OP35 20 3. OP38 23 Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 Page 22 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 OP9 Good Practice Recommendations The inspector recommends that the statement made in the Service User Guide and the contract informing service users that the home will take care of their medication should be reconsidered. The inspector recommends that details of any leisure activities (including visitors seen and time spent out of the home) are recorded in a service user’s care plan. An activities programme should be displayed to inform service users of any planned events. The inspector recommends that the registered person develops a specific training and development programme to evidence that Skills for Care workforce training targets are met. The results of quality questionnaires should be collated and published. Other stakeholders should be included in the quality monitoring process. 2. OP12 3. OP30 4. OP33 Keldgate Manor DS0000019685.V261640.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor, 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 DS0000019685.V261640.R01.S.doc Version 5.1 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. 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