Inspection on 06/09/07 for Keldgate Manor

This inspection was carried out on 6th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Keldgate Manor 01/09/09

Keldgate Manor 17/02/06

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 Key Unannounced Inspection 6th September 2007 09:30 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.V350453.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 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.V350453.R01.S.doc Version 5.2 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 kme@supaworld.com 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.V350453.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 2006 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. Information about the home is provided to service users and others in the home’s statement of purpose and Service User’s guide. The registered provider/manager informed the inspector that fees paid range from £334.80 to £381.30 per week and there is an additional charge for hairdressing, chiropody, newspapers, toiletries and outings. 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. Private 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.V350453.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on the 14th September 2006, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day. It began at 9.30 am and ended at 4.30 pm. On the day of the site visit the inspector spoke on a one to one basis with three residents, a relative, a senior carer and the registered manager/provider as well as chatting to other residents and staff. Inspection of the premises and close examination of a range of documentation, including four care plans, were also undertaken. The registered manager submitted information about the service in advance of the site visit by completing and returning an annual quality assurance assessment (AQAA). Survey forms were sent out prior to the inspection; four were returned from relatives, two were returned from staff and four were returned by residents. Comments from returned surveys and from discussions with residents, staff and others were mainly positive, for example, ‘The staff are friendly and capable and look after my relative well’ and ‘they cannot get any better than they are’. Comments from surveys and from discussions on the day of the site visit will be included, anonymously, throughout the report. The inspector would like to thank residents, staff and the registered manager/provider for their assistance on the day of the site visit, and to everyone who completed a survey. What the service does well: People are only offered accommodation at the home if an assessment evidences that their needs can be met. Care planning at the home is good and people are involved in developing their own plan of care. Regular reviews of peoples’ needs take place and this results in ‘up to date’ care plans being used by the home. Meal provision at the home is excellent; people get a choice at every mealtime and menus offer a wide variety of meals. Staff ensure that mealtimes are a social occasion. People living at the home are supported to maintain their chosen lifestyle, and are encouraged to take part in activities inside and outside of the home. The home provides people with attractive, comfortable, well-furnished and well-decorated accommodation. Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 6 Staff turnover is low and this results in consistency of care for the people living in the home. 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. Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 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.V350453.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4. Standard 6 was not assessed, as there is no intermediate care provision at the home. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are only offered accommodation at the home following a full assessment of their individual needs that evidences that these can be met by the home. Most staff have not undertaken training on dementia care; this would ensure that they are fully trained to meet the needs of the people accommodated at the home. EVIDENCE: Records at the home evidence that people are visited by the registered manager and the care manager when they initially make enquiries about admission, and that the assessment process commences at this stage. A full assessment of needs is completed and prospective residents are only offered accommodation at the home if this assessment evidences that their needs can Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 9 be met by staff. Prospective residents and their relatives are invited to look around the home as part of the assessment process, and some people initially attend the home for respite care to assist them in making a decision about permanency. Community care assessments and care plans are obtained from Social Services for anyone who is placed at the home by them, and this information is used along with the assessment undertaken by the home to develop an individual care plan. Staff are skilled and well trained, although they should undertake training on dementia care to ensure that they are fully equipped to meet the needs of the people accommodated at the home. Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of people are met in a way that respects their privacy and dignity. Medication is administered, recorded and stored safely and this protects people from the risk of harm. EVIDENCE: The inspector examined four care plans; these included a copy of the home’s own assessment and a community care assessment and care plan undertaken by the local authority Social Services Department, where appropriate. Care records contained a detailed risk assessment for all areas of personal care including pressure care, moving and handling and nutrition. The care plan records the information needed to enable staff to offer appropriate assistance to people, including a ‘self care’ checklist that records the personal care tasks that people are able to manage without assistance. The inspector noted that some documentation in care plans, i.e. personal profiles, have been written by Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 11 a relative of the resident; this gives a ‘personal touch’ to these records and is good practice. People also sign a document that records their agreement to their individual plan of care. People have had a meeting to formally review the content of their care plan; this is usually on an annual basis. Monthly in-house reviews of the care plan and risk assessments also take place and any changes to care plans are recorded at the front of the care plan so that all staff are alerted to these; this is good practice. One relative recorded in a survey, ‘the staff are friendly and capable and look after my relative well. She is very happy there and I am grateful for the care provided’. A record is kept of all contact with health care professionals; these include the reason for the contact and any outcome. There is evidence that specialist health professionals are consulted about a persons care when this is appropriate. Accident reports are recorded in individual care plans and there is a system in place to monitor all accidents within the home. In addition to this, a ‘special notes’ form is used to record accidents and any particular health concerns. Continence care and pressure care are promoted at the home. A person’s individual needs regarding continence care and pressure care are recorded in assessments and care plans, and reviewed appropriately. Any areas of concern are clearly recorded in care plans, and some residents have been provided with special pressure care equipment such as mattresses and cushions. A person’s weight is monitored as part of nutritional screening. Medication is stored in a locked cupboard in the manager’s office; it is transferred to a lockable trolley to be transported around the home at the times medication is administered. There is a separate medication fridge in the same office; the senior carer informed the inspector that fridge temperatures are taken and recorded on a daily basis although these could not be found on the day of the site visit. Unused medication is returned to the Pharmacist as required, and the Pharmacist signs the returns book. The inspector observed medication being administered at lunchtime – people were provided with a drink with which to take their medication, and all were observed by staff to ensure that they actually took their medication. None of the current residents are prescribed controlled drugs but there are suitable storage and recording facilities available should this occur. Administration records were examined by the inspector and these were found to have a small number of gaps in recording; these appeared to be when residents have refused their ‘as required’ medication; more care should be taken to complete medication administration records accurately. Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 12 The manager informed the inspector that staff that administer medication have undertaken accredited training; there was a list of the names of these staff with sample signatures to enable medication records to be checked. On the day of the site visit the inspector observed that staff treat people with respect and that their privacy is maintained as far as is possible; the inspector observed that people were assisted with eating their meals and with personal care in a sensitive manner, and people told the inspector that staff respect their privacy. Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in activities both inside and outside of the home and are encouraged to maintain relationships with family and friends. Visitors to the home are made welcome and meal provision at the home is excellent. EVIDENCE: Care plans record details of a person’s previous lifestyle, including leisure and social interests; some personal profiles have been written by relatives and this provides a good insight into the previous lifestyle and history of the person concerned. There is an individual record of activities undertaken, visitors seen and time spent out of the home in care plans. These record such things as ‘sat in the garden’, ‘watched a film’ or ‘watched TV’, but not whether people have taken part in the organised activities. Most organised activities take part in communal areas of the home and information about these activities is recorded on a separate calendar; activities Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 14 such as a quiz, bowls and outings are recorded. One member of staff works 8.00 am – 4.00 pm Monday to Friday; she works as a carer each am and as an activities organiser in the afternoons. ‘Music and dance’ was the theme on the day of the site visit. The inspector recommends that this information should be cross-referenced to care plans so that there is a full record of all care provided for people. Discussion with residents and information seen in care plans evidenced that people that have friends and relatives are supported to remain in contact with them. Visitors told the inspector that they are always made welcome by staff at the home. One relative said, ‘I find the staff to be extremely courteous and friendly. My relative always says that they are “lovely girls”’. When asked in the survey, ‘How could the home improve?’ one relative stated, ‘They cannot get any better than they are!’ The inspector observed that people had personalised their bedrooms to the extent chosen by them; some people had brought small items of furniture into the home as well as pictures, ornaments and photographs. Information about advocacy services are made available to services users and visitors in the information booklet displayed in the entrance hall. People told the inspector that they can choose what time to get up and what time to go to bed, whether or not to join in activities and where to take their meals. People told the inspector that this changes from day to day; they are not expected to have a set routine. A menu is displayed in the home and this evidences that a good quality threecourse meal is provided every lunchtime. There is a choice of main meal and dessert at both lunchtime and teatime. There is an eight-week menu in operation and the inspector observed that a wide variety of main meals are on offer – this provides service users with ample choice. The dining room is situated in a large conservatory and the inspector observed that there was a pleasant and relaxing atmosphere over lunch and that people were offered appropriate assistance with eating and drinking. The menu also records afternoon tea and this lists such things as ice-cream cornets, fruit and rum truffles. The inspector observed tea and cake being served on the afternoon of the site visit to the home. Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and relatives are aware of the complaints procedure and of how to make a complaint; there is evidence that complaints are dealt with effectively by the home. There are appropriate policies and procedures in place on safeguarding adults to alert staff to the importance of this issue, and all care staff have undertaken appropriate training. EVIDENCE: The AQAA recorded that one complaint had been received since the last inspection of the home. The inspector examined documentation regarding this complaint, and this evidenced that the complaint had been dealt with in a satisfactory manner and within required timescales. The four residents and four relatives that returned a survey all recorded that they knew how to make a complaint, and residents added that staff listen and act upon what they say. The inspector noted that the complaints procedure and a complaints form are displayed in the home. Training and development records evidence that the topic of safeguarding adults is included in Induction training for new staff, and that all staff have undertaken specific training on safeguarding adults. In addition to this, nine of the eleven care staff have undertaken a National Vocational Qualification Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 16 (NVQ) at Level 2 (or above) in Care – this award includes training on safeguarding adults. There are appropriate policies and procedures in place at the home and there have been no recorded incidents or allegations made. Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides residents with clean, attractive, comfortable, well-furnished and well-maintained accommodation. EVIDENCE: The inspector toured the premises and observed that the home is well maintained, although the carpet in the corridor to the staff room and kitchen is worn. This area of the home is in the process of being redecorated and the carpet should be replaced when the redecorating is finished. Other carpets throughout the home are of good quality and in a good state of repair. There is a maintenance log in place and this is a thorough record of all repairs and refurbishment that has taken place; the outside of the home has been decorated recently. A handyman and a gardener are employed. Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 18 The home has a large attractive garden that is enjoyed by residents and visitors. It includes flowerbeds, a summerhouse, a pond and garden furniture. A large conservatory has been added to the rear of the property; this is used as a lounge and a dining room and allows residents ample access to sunlight and fresh air. The inspector noted that one of the shower cubicles is in need of replacement as it is starting to look shabby. Two bedrooms had an unpleasant odour; this was discussed with the senior carer on duty and it is evident that efforts are being made to alleviate this problem. The only solution may be for new carpets or beds to be purchased. Laundry facilities at the home are good and one of the washing machines has a sluice facility; this reduces the need for staff to manually sluice soiled linen and clothing. There is a separate toilet and separate hand-washing facilities for staff in the laundry room and the inspector observed good hygiene practices being followed by staff throughout the day. Three care staff have attended training on infection control and the inspector was informed that arrangements have been made for two senior staff to attend Infection Control ‘Training for Trainers’ and that these staff will then cascade this training to the rest of the staff group. There is evidence that the home meets the Water supply (Water fittings) Regulations 1999. Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a low staff turnover and this results in consistency for people living at the home. Staff undertake Induction training, core training and more specialised training programmes to equip them to carry out their roles effectively. EVIDENCE: The staff rota records all staff on duty, including ancillary staff, and records the role in which each person is employed. The rota evidences that there are sufficient staff on duty to meet the needs of those living at the home. The registered provider/manager informed the inspector that no agency staff are used at the home. Any absences through sickness or annual leave are covered by other staff; this results in consistency for residents. Domestic and catering staff are employed, and one of the domestic staff is allocated work in the laundry room each day. This results in care staff being able to concentrate on the personal and social care needs of residents, and reduces the risk of cross infection. Nine of the eleven care staff have achieved a NVQ Level 2 (or above) in Care and another member of staff is working towards this award. Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 20 There is a low turnover of staff at the home and no new staff have been employed since the last inspection of the home. The only change has been that a domestic assistant has undertaken training so that they could become a care worker. The registered provider/manager assured the inspector that any new staff would have two written references and a Criminal Records Bureau (CRB) check in place prior to them commencing work at the home. Staff records seen by the inspector include clear information about Induction training undertaken by staff. Each member of staff has an individual training record and there is also a training and development plan that records all training undertaken by staff. The training and development plan now records the dates that staff have undertaken training; this assists with identifying when refresher training is needed. There is evidence that most staff have undertaken core health and safety training such as moving and handling, health and safety, fire safety, food hygiene and safeguarding adults. Most staff have undertaken first aid training but some of this was done in 2004 and should now be updated. More specialised training programmes such as dysphasia awareness, osteoporosis awareness, ‘Making the most of Menus’ and ‘Chair based Fun Activity Programme’ have been undertaken by some staff. Staff have also attended study days on topics that are of interest to the care home, such as ‘Stay Steady’. This results in a staff group that are skilled and trained to care for the people living in the home. However, training on dementia care would strengthen the skills and knowledge base of the staff group. The inspector noted that there was information in the staff room informing staff about the signs and treatment of Scabies and about the Mental Capacity Act; staff had signed to say that they had read the information on the Mental Capacity Act. Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and the health, welfare and safety of service users and staff are protected, with the exception of the control of water temperatures. EVIDENCE: The registered provider/manager is experienced, competent and qualified to manage 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. The registered Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 22 provider/manager now works part time and the deputy manager is effectively the ‘day to day’ manager of the home. She has achieved NVQ Level 3 in Care and is now working towards the NVQ 4 Registered Manager’s award and NVQ 4 in Care. Both managers keep their practice up to date and there is evidence that the care manager has attended various training sessions during the last year. There are clear lines of accountability within the home. Residents meetings and staff meetings continue to be held on a regular basis. The home has achieved QDS (the local authority quality assurance scheme) parts 1 and 2. Service users and/or their advocates complete a quality questionnaire prior to their six-monthly or annual review. This asks a wide variety of questions about the care provided by the home. The AQAA records that 44 questionnaires were completed from the 1st January 2006 to the 1st January 2007; the outcome of these questionnaires has been collated and a graph has been prepared to demonstrate the results. A copy of this is sent to the local authority as part of the QDS monitoring process, but is not displayed within the home. It is recommended that this information should be displayed on the notice board or discussed at staff and resident meetings so that everyone that takes part in surveys is informed of the outcome. It is also recommended that staff, health and social care professionals and others be involved in the quality monitoring process. Some personal allowances are held on behalf of residents; the inspector observed that these monies are held securely. A sample of these records and associated monies were checked by the inspector and were found to be accurate. Some people manage their own financial affairs with assistance from relatives and advocates. The inspector examined health and safety documentation in place at the home. This evidenced that equipment and appliances are serviced regularly and are well maintained, including an annual test of the fire alarm system and a gas safety inspection. In-house fire tests take place weekly and fire drills are held as part of the six-monthly staff training sessions. There are risk assessments in place for safe working practices, including a fire risk assessment that is reviewed annually. Most staff have completed training on health and safety topics. Accident reports are recorded in individual care plans; this ensures that the home is adhering to the Data Protection Act. There is a system in place at the home to monitor accidents and the graph recording these evidences that the incidence of accidents had decreased. Staff record the temperature of the bath water every time they assist someone with a bath; these records were seen by the inspector. Checks on water temperatures in washbasins in bedrooms also take place; these records could not be found on the day of the site visit but these were later forwarded to the inspector. These evidence that water temperatures in outlets accessible to Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 23 residents are at 50°C and they should be at around 43°C. The inspector contacted the registered person who had already recognised that these temperatures were too high and has arranged for a plumber to visit the home to rectify the problem. The registered person informed the inspector that ‘hot water’ signs are in place above all hand washbasins and that any residents that are considered to be at risk of harm do not run the water in their washbasin; this is done by staff. Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 25 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 OP38 Regulation 23 Requirement Water temperatures must be controlled to be close to 43°C at outlets accessible to service users. Previous timescales of 30/4/06 and 30/11/06 not met. (The registered person informed the inspector following receipt of the draft report that there will be a planned programme to have regulators fitted to all taps). Timescale for action 31/01/08 Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 26 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 OP4 OP30 OP9 OP12 Good Practice Recommendations Staff should undertake training on dementia care to further equip them to meet the needs of service users accommodated at the home. More should be taken when recording medication ‘not required’ or ‘refused’ by residents. The inspector recommends that activities recorded on the calendar should be cross-referenced to care plans to ensure that a full record of a person’s care package is recorded on one place. The identified shower unit should be replaced, and the carpet in the corridor to the staff room and kitchen should be replaced. (The registered person notified the inspector following receipt of the draft report that the shower unit has been replaced). Every effort should be made to alleviate strong odours in two of the bedrooms. The results of quality questionnaires should be published and other stakeholders should be included in the quality monitoring process. 4. OP19 5. 6. OP26 OP33 Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Keldgate Manor DS0000019685.V350453.R01.S.doc Version 5.2 Page 28 - 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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