Inspection on 17/11/05 for Kelso

This inspection was carried out on 17th November 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

Kelso 04/10/08

Kelso 20/10/06

Kelso 24/01/06

Kelso 14/03/05

Kelso 11/01/05

Kelso 30/01/04

Kelso 16/05/02

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Kelso 10 Clifton Road Southbourne Bournemouth Dorset BH6 3PA Lead Inspector Rosie Brown Unannounced Inspection 11:00 17 November 2005 th 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 Kelso DS0000020474.V268571.R01.S.doc Version 5.0 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. Kelso DS0000020474.V268571.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kelso Address 10 Clifton Road Southbourne Bournemouth Dorset BH6 3PA 01202 432655 01202 432655 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) Mr Kenneth Alan Ackrill Mrs Angela Elizabeth Ackrill Mrs Angela Elizabeth Ackrill Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Kelso DS0000020474.V268571.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. NVQ4 in Management to be successfully completed within 18 months of date of registration by applicant - Mrs Angela Ackrill. 14th March 2005 Date of last inspection Brief Description of the Service: Kelso is a private care home providing nursing care and accommodation for 12 older people. The home is owned by Mr & Mrs Ackrill. Since the previous inspection Mrs Ackrill has become the Registered Manager with the condition that she completes NVQ 4 management training within 18 months. The staff team work closely with the Mrs Ackrill in respect of the day-to-day management of the home. The home is located in the Southbourne area of Bournemouth, close to the seafront, shops, pubs, and the post office. The home was opened in 1988 and consists of a two-storey building with a large lounge/dining room. Four of the home’s bedrooms are single, and four are double rooms. Bedrooms that are situated on the first floor are accessed by the main stairs or a passenger lift. The communal assisted bathroom is situated on the first floor and a separate toilet is available at ground floor level. The home has gardens to the front and rear of the building: these are well maintained and easily accessible with the aid of a portable ramp. Kelso DS0000020474.V268571.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place on Tuesday 17th November 2005 at 11:00am. The inspection was the first of two statutory inspections to be carried out at Kelso nursing Home since 1st April 2005. This was the first time the inspector had visited the home, the inspection was positive and a favourable impression was gained. Fifteen of the National Minimum Standards were reviewed during the visit as were one requirement and 5 good practice recommendations set out in the last inspection report dated 14th March 2005. This report contains one requirement and two recommendations. Information was gathered through general observation, discussion with Mrs Ackrill, the nurse in charge of the shift, one care staff and the cook/carer on duty at the time. A tour of the premises and examination of the records available provided further information. On the day there were 12 residents accommodated in the home. The inspector was able to talk with two service users in the privacy of their rooms and two visitors. What the service does well: This home provides residents with good quality nursing care, in a homely family style environment. Twelve of the 15 National Minimum Standards assessed during this inspection were met. Residents’ pre admission assessment information and care plans are detailed and routinely updated: residents’ needs are well known by staff. The standard of food supplied to service users is very good: wholesome and freshly baked with seasonal variations and special dietary needs catered for. The home is well maintained and residents’ bedrooms are highly personalised. A staff training and supervision programme is in place and is considered integral to the provision of good quality care. Kelso DS0000020474.V268571.R01.S.doc Version 5.0 Page 6 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. Kelso DS0000020474.V268571.R01.S.doc Version 5.0 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 Kelso DS0000020474.V268571.R01.S.doc Version 5.0 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): 3 and 6 Each prospective resident is subject to a pre admission assessment, which is undertaken by Mrs Ackrill to ensure that the home can meet assessed needs. The home does not provide intermediate care. EVIDENCE: The care record for one recently accommodated resident evidenced that Mrs Ackrill, undertook a pre admission assessment to establish the prospective service user’s care needs prior to admission. The details obtained included all recommended topics and nursing information from the hospital. Mrs Ackrill now provides written confirmation that the home can meet the resident’s care needs prior to admission and the person with Power of Attorney signed all documents. One resident confirmed that they decided to stay permanently in the home following a short trial stay and feels very happy about the decision. Kelso DS0000020474.V268571.R01.S.doc Version 5.0 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): 7, 8 and 10 Each resident has a care plan that identifies the care being provided to meet identified needs. Service users’ health needs are closely monitored and responded to appropriately with support from community services. Two residents confirmed their privacy is protected and that their known wishes are respected. EVIDENCE: The care plans and associated records for three residents were examined. Care plans provided clear guidance for staff to determine how each identified need should be met. Daily care notes and records demonstrated that other care professionals are contacted for guidance and assistance when needed, for example one resident’s care manager had been contacted by Mrs Ackrill to bring forward their care review. Kelso DS0000020474.V268571.R01.S.doc Version 5.0 Page 10 The home keeps records of each accident that occurs and the care plan for one resident indicated a change in care needs following a fall. Care related risks are documented and referred to in the care plan. Two residents said that their wishes are respected by staff and that their privacy is upheld. For example; one resident was sitting in the lounge with the patio style window/door open because this is what they like to do. Another example was the use of screens in double rooms. The inspector also noted that residents’ preferred names are used by staff. The two recommendations relating to recording of residents medication are met: Kelso DS0000020474.V268571.R01.S.doc Version 5.0 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): 13 and 15 Residents’ visitors are welcomed by the home and community contact is maintained where possible. Residents said that the meals and food supplied by the home are very good offering both choice and variety and catering for special dietary need. EVIDENCE: Two residents confirmed that their visitors are made welcome. The home’s visitors’ book and daily records indicated that visitors call into the home on a regular basis. Two visitors confirmed they call into the home at any time to see their relative: they said they were impressed with the happy family style atmosphere and are very satisfied with the way their relative is cared for. The home employs a cook each day to bake the main meal. Records of all food supplied to residents is kept in a diary in the kitchen and evidenced that a good variety of wholesome seasonal food is given to residents. The cook explained that most residents have their meals in their rooms due to frailty or medical condition: six residents are supplied with a pureed diet and feed by staff. Kelso DS0000020474.V268571.R01.S.doc Version 5.0 Page 12 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): 16 The home’s complaints procedure is supplied to residents and their representatives and one resident confirmed that their concerns are taken seriously. EVIDENCE: The home has a complaints procedure and this is also detailed in the Statement of Purpose and guide. The home also keeps a complaints record book. Mrs Ackrill said that grumbles are dealt with promptly so that ‘we keep everyone happy’. There have been no complaints received by the home or the Commission in the past year. One service user said, ‘they sort things out if there’s a problem’ and another said ‘I feel safe in this home’. Kelso DS0000020474.V268571.R01.S.doc Version 5.0 Page 13 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): 19 and 26 The home is very clean and maintained to a high standard; it provides an attractive and comfortable homely environment for the residents who live there. Service users rooms are personalised, furnished and equipped in a manner that is suitable to their individual needs. EVIDENCE: The home is located close to the beach and local amenities; it is suitable for its stated purpose. The inspector viewed all bedrooms and communal areas during this visit. The home is safe, well maintained and homely. Mrs. Ackrill reported that the lounge/dining room had been redecorated and re-carpeted since the previous inspection. The lounge provides a pleasant view of the garden and easy access to the back garden with the use of a ramp from sliding patio doors. The home has four single rooms and four double rooms. All bedrooms in the home meet the spatial standard but do not have en-suite facilities: they are furnished and equipped to assure comfort and meet the needs of the resident. Kelso DS0000020474.V268571.R01.S.doc Version 5.0 Page 14 The inspector noted that incontinence pads are stored in attractive hangers and that toilet paper is readily available and next to commodes. The home’s bathroom is situated on the first floor and is equipped with a bath seat to aid bathing: there are separate toilet facilities on both floors of the home. The home has two sluice rooms: one on each floor and the laundry is established in the garage area. On the day of the visit it was clean, hygienic and free from offensive smells. Two visitors confirmed that the home is always clean and that in seven years they have been visiting their relative they never noticed an odour. There is a small driveway to the side of the house free street parking outside of the home for visitors. Kelso DS0000020474.V268571.R01.S.doc Version 5.0 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): 27, 28, 29 and 30 Appropriately staffed 24hrs each day by management, care and domestic workers to ensure that service users needs are met at all times. The process of staff recruitment is robust thereby ensuring the protection of residents living in the home. A training and supervision programme has been set up in the home to ensure that nursing and care staff are appropriately trained to meet service users needs. EVIDENCE: The staff rota demonstrated that there is a Registered Nurse and a Health Care Assistant on duty at all times (day and night) and this was the case when the inspector arrived at the home unannounced: the cook was also on duty. Staff said that Mrs Ackrill was on a day off but normally works in the home each day in addition to the staff team. Mrs Ackrill promptly arrived at the home to assist the inspection process when informed by staff of the inspector’s presence. The recruitment records for one new member of staff was examined and this detailed that all necessary checks and information was obtained before they commenced working in the home. Records showed that the new staff member was subject to induction training that meets NTO specifications. Kelso DS0000020474.V268571.R01.S.doc Version 5.0 Page 16 A discussion took place regarding the POVA guidance issued by the Department of Health in July 2004 and that this information should be referred to in the home’s recruitment procedures for future reference. Two members of staff said that training opportunities are good and that Mrs Ackrill is keen to keep up to date and one showed the inspector their NVQ course work file. A programme of NVQ training has been set up to ensure that 50 of the care staff working in the home are NVQ trained: this target has yet to be fully achieved. Records demonstrated that care staff and nurses are supplied with supervision and clinical supervision. Since the previous inspection staff have undertaken training in; manual handling, anaphylaxis, medicine administration and management, MRSA research, catheter care and urinary infections, Whistle blowing, infection control and health & safety. Kelso DS0000020474.V268571.R01.S.doc Version 5.0 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 and 38 The registered provider/manager, Mrs Ackrill is suitably experienced: she has yet to achieve an NVQ 4 management qualification. The home continues to provide a good standard of care to residents, and a documented quality assurance system that takes into account the views of residents is in place. Arrangements are in place to ensure that the health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: Mrs Ackrill has relevant experience in residential care. She has run and managed the home in a positive and organised manner with the assistance of senior nursing staff for almost 20 years. At the time of the last inspection the home’s Acting Manager had recently left Kelso DS0000020474.V268571.R01.S.doc Version 5.0 Page 18 full time employment .The Inspector discussed options for appointing a Registered Manager and since then Mrs Ackrill submitted a successful application to CSCI. Mrs Ackrill is now the home’s Registered Manager on condition that she achieves an NVQ level 4 management qualification within 18 months from the date of registration: she has commenced this training. Kelso is signed up to the Registered Nursing Home’s Association’s quality assurance policy, which makes a commitment to running the home in the best interests of Service Users. The home considers and responds to quality issues on a continuous basis. The quality assurance system is supported by training, staff supervision and feedback from Service Users and relatives. Records demonstrated that care staff and nurses are supplied with training in manual handling, food hygiene, first aid, control of infection and fire safety. The home has a comprehensive policies and procedures manual for staff reference and practice guidance. The home’s fire records demonstrated that the regular in house tests and routine servicing of the fire safety system and equipment are up to date. Other maintenance records evidence that routine checks of the central heating system, hot water supply, sluice facilities, moving and handling equipment and passenger lift are undertaken and certificated documentation is in place. Kelso DS0000020474.V268571.R01.S.doc Version 5.0 Page 19 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X X 3 Kelso DS0000020474.V268571.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Care plans must include information about residents’ needs regarding terminal care, dying, living wills, resuscitation and so on. Timescale for action 31/12/05 1 OP7 14 & 15 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP29 OP31 Good Practice Recommendations The home’s recruitment and employment policies should be updated to reflect the POVA guidance. Mrs Ackrill should complete the relevant management training within the conditions on the home’s registration certificate. Kelso DS0000020474.V268571.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Kelso DS0000020474.V268571.R01.S.doc Version 5.0 Page 22 - 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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