Inspection on 23/08/06 for Kemp Lodge

This inspection was carried out on 23rd August 2006.

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

Kemp Lodge 01/06/07

Kemp Lodge 18/01/06

Kemp Lodge 06/05/05

Kemp Lodge 14/12/04

Kemp Lodge 21/06/04

Kemp Lodge 30/03/04

Kemp Lodge 23/04/03

Kemp Lodge 19/06/02

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

CARE HOMES FOR OLDER PEOPLE Kemp Lodge Haigh Road Waterloo Liverpool Merseyside L22 3XG Lead Inspector Mrs Joanne Revie Unannounced Inspection 23rd August 2006 10:00 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 Kemp Lodge DS0000017245.V302278.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. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kemp Lodge Address Haigh Road Waterloo Liverpool Merseyside L22 3XG 0151 949 0826 0151 928 0641 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) www.c-i-c.co.uk. Community Integrated Care Mrs Helen Cook Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service Users to Include up to 38 (OP) One named female out of category service user, under pensionable age. The variation to cease when the service user leaves the home. One named female out of category service user, EMI Personal Care. This variation is applicable only to the named service user, should the named service user leave the home the variation will cease to apply. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 4. Date of last inspection Brief Description of the Service: Kemp Lodge Care Home is a purpose built facility that provides nursing care for 38 older persons. The home is located in a residential area in the Waterloo, Merseyside area close to local amenities and public transport, such as local buses and a train station approximately 10 minutes walk away. The Home is built on one level in grounds that it shares with a sister home next door. The grounds are well maintained and accessible by the residents. The Home is owned by a voluntary organisation Community Integrated Care (CIC) and has been operating since 1990. All bedrooms are en-suite with 24 single rooms and 7 double rooms. There are three small lounges and a dining room. There is also a relatives area that provides drinks and a notice board that supplies information of interest to the relatives. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was unannounced and took place over seven hours. An unannounced visit took place at Greenheys (sister home) recently therefore some national minimum standards, which refer to the organisation, were not assessed during this visit as no changes had occurred and theses were assessed during the visit to Greenheys. Discussions were held with three residents, one relative and four staff members and the manager. Their comments have been included in the summary section of the report. A variety of documentation was viewed which is referred to in the evidence section of the report. A tour of the environment took place and staff were observed carrying out their duties. Three residents were “ case tracked”. This means that their experience of the home was examined closely. This helps to give a snapshot of what it is like to live at the home. The home charges between £600.00 and £ 463.50 per week. Some extra charges are required such as chiropody, newspapers etc but these are explained in the written information provided to interested parties. What the service does well: Each resident receives a full assessment before admission takes place. This means that the home can plan to meet the resident’s needs. One resident confirmed that this had been reassuring and that it was “nice to see a friendly face”. This resident’s relative stated that they had felt involved in the admission process and that this had stopped her from worrying whether she was “doing the right thing”. Resident’s health care needs are generally well met. Steps are taken to monitor health care so that health care crisis’s can be avoided. Residents commented that the “girls are great”, “Im well looked after”, “they always come as soon as I ring my bell” and “they understand that I want to be independent but they’re there to help when it gets too much”. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 6 The home employs a full time activities coordinator. She is enthusiastic about her role and as a consequence three different activities are provided daily on weekdays. Examples include trips out to places of interest, personal shopping, group activities such as quizzes and bingo, film shows, dominoes and card games. The home is a comfortable clean place to live and is decorated and furnished to a good standard. It has three lounges one of which is a quiet lounge and also provides a small relatives room with drinks making facilities. Residents are encouraged to make their bedrooms their own as they would in their own home. Visitors are welcomed by the staff at the home and are supported to be involved in the residents care if they so desire. Staff offer choice wherever possible. Residents confirmed this during discussions by saying “Im always offered choice” and “Yes, Im in control of my life”. The Cook should be commended on the quality and presentation of food provided by the home. Residents comments included “the foods so good I ve started eating again” “I really look forward to mealtimes, everything is so nice” “we have a marvellous cook, nothing is too much trouble” and “she knows what I like and if Im having an off day she’ll make me something little and tasty until Im back on my feet again- its marvellous” Residents and relatives believe that their concerns are acted on and that the manager is approachable and quickly resolves any issues. The service should be commended on the number of staff provided each day, which at times is greater than expected for a home of this size. The national minimum standards suggest that 50 of staff should obtain an NVQ qualification or equivalent. With the exception of two staff who are undertaking the award, all staff have achieved this status. The service has robust recruitment procedures, which help to protect vulnerable people. Staff have the skills to meet the residents needs and a variety of training is regularly offered. Staff commented that the training was” very good” and “if we show an interest in a particular area they will try and find some training on it for us” What has improved since the last inspection? The management of wound care has improved since the last inspection although some further improvements are required. However, the requirement that was made following the last visit has been addressed. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 7 A lot of work has been undertaken around the management of medications. This means that medications are now managed safely and the risk of a mistake occurring is greatly reduced. Staff have received training on a variety of subjects since the last inspection. This includes Protection of Vulnerable Adults, administering thicken fluids, moving and handling, Cardiac Pulmonary Resuscitation, Abuse awareness, Fire prevention, Protection of Vulnerable Adults Awareness, mentorship training, phlebotomy, Diabetic foot care, Psychosocial intervention, and falls risks assessment. These are all subjects, which help to keep residents care safe The home has addressed the recommendations made by the fire officer, which means that the home is a safer place to live. A Sweet trolley with small toiletries etc has been provided to enable residents to purchase small items on a daily basis The organisation has developed internal quality audits in some areas, which means that the level of service provided is assessed regularly to ensure standards are maintained. What they could do better: Some care plan documentation was viewed which was well written and clearly reflected the resident’s choices and preferences. However, other documentation was viewed which did not. This must be addressed, as staff need clear written instructions to follow. Although improvements have been made in wound care staff are not monitoring the size of wound. This must be addressed by either introducing wound mapping or taking photographs so that a clear record exists of whether wounds are healing or not. Generally risk is managed well by the home . However one risk assessment viewed did not clearly reflect the change in the residents needs. This must be addressed. Although great improvements have been made in the management of medications it was noted that some creams had not been signed for to show that they had been administered and not every resident had a photograph on file. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 8 This should be addressed to further reduce the risk of mistakes occurring Following the recent visit to Green heys (sister Home) two requirements were made which also affect this home. Therefore, these have not been repeated in this report. However, the requirement issued requesting the formulation of a personal file for the manager and the introduction of regular practice fire evacuations must be carried out. 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. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 9 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 Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 10 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 The quality outcome in this area based on available evidence is good. Residents receive information to help them to decide whether they want to live at the home. Staff make sure that they receive as much information as possible about a residents needs so that they can decide whether Kemp Lodge is a suitable place for the resident to live. EVIDENCE: The home does not provide intermediate care therefore standard 6 is not applicable. A discussion was held with a resident and a relative who has recently moved to the home. The residents care plan was viewed. Two other care plans were also viewed. The resident confirmed that staff from the home had visited him before he had moved in. He explained that he had found this reassuring. Documentation showed that assessments are undertaken by senior staff who work at the home. A copy of the homes own assessments was viewed which appeared comprehensive and covered the usual activities of daily living. It was evidenced that the home also obtains other assessments, which are relevant from other health care professionals, e.g. Hospital social worker etc. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 11 A relative confirmed that the resident had received written information about the home and that staff had discussed the resident’s needs with her. She confirmed that this had helped her to feel involved in the process. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10 The quality outcome in this area based on available evidence is adequate. Care plan documentation varies in standard with some parts being detailed and other parts not . Health care needs are monitored and addressed although wound care documentation needs further development. Medications are managed safely. Residents are treated with respect. EVIDENCE: Three care plans were viewed. The amount of information within these plans varied. A different staff member had written each of these. One plan contained all the required information but did not include any preferences such as bed and rising times etc or what was important to the resident. This plan showed little involvement from the resident and contained no information about how the resident liked to spend their time or how they would like to participate in activities. Another plan viewed was detailed and contained preferences such as rising and bed times and how the resident wished to maintain personal hygiene. This also contained information about past interests and hobbies s but did not provide instructions on how staff were to continue support with this. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 13 Some evidence was available which showed that the resident’s relative had been consulted and involved regarding the resident’s needs. All plans viewed were reviewed monthly and contained photographs and personal details (such as next of kin, G.P. etc). During the recent visit to Greenheys the manager explained that the organisation has developed new documentation which staff would find easier to complete and that this should ensure that all areas of care were assessed and recorded. She also explained that it was hoped that this would be implemented in the near future and would be used at both Kemp Lodge and Greenheys. During discussions three residents confirmed that they believed that they were well looked after and that the staff knew how to care for them. A relative supported this view also. Three care plans that contained information about the resident’s health needs were viewed. These contained assessments regarding the residents nutritional status, risk of developing pressure sores and the risk of using associated equipment to prevent pressure sores occurring where required. These assessments were up to date and in most cases were being regularly reviewed. Residents had also been assessed regarding the risk of falls occurring and were identified, appropriate action had been taken. Evidence of dental, chiropody and optician visits had been recorded which showed that dental health, foot care and eyesight were being monitored. The plans also contained records of the resident weight, which was being reviewed on monthly basis. All residents files viewed showed that on admission each resident has their temperature, pulse and blood pressure recorded as a baseline so that staff had information to refer to should a variation occur. Each plan contained details of the residents G.P, when and why they visited and any action taken following this. Two residents were identified as suffering from pressure sores. Appropriate equipment was being used to help promote healing and one of these residents was viewed in bed, appearing comfortable and well cared for. A requirement was made following the last inspection that staff should record all pressure ulcers. Clear recordings were found within the plans however the wounds had not been mapped so no records existed to show that the wounds were decreasing in size and healing, although staff confirmed that healing was taking place. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 14 In one plan the residents waterlow score had been updated monthly however the score had remained the same despite this resident developing a pressure sore. This would suggest that the score is not a true reflection of the resident’s risk of developing pressure sores. During a discussion with the cook it was evidenced that she had knowledge of specialised diets and she confirmed that these could be provided if required. When assessing medications, records were viewed which showed that residents who have diabetes, when appropriate, are having blood sugar levels monitored according to the severity of the diabetes. A number of requirements were issued following a pharmacy inspection earlier this year. It was evidenced during this visit that these have been addressed and auditing systems developed to monitor whether staff are managing medications safely. The management and recording of controlled drugs was assessed and no short falls were found. Staff have developed clear lines of auditing by recording all medications that come into the building and all medication that leaves. A copy of a contract for clinical waste disposal was viewed which was current. The medication administration records were viewed. All medications were signed for with the exception of two different creams were the signature space had been left blank. It was noted that the file contained 34 photographs of residents yet 38 were residing at the home on the day of the visit. Good practice was evidenced as staff had recorded whether residents preferred to self-administer and how much support was required to enable residents to manage their medication safely. Staff were observed delivering care and supporting residents to meet their needs. In many instances staff and residents were laughing together which appeared as though they enjoyed one another’s company. Staff were heard to be calling residents by names of their choice and were observed knocking on bedroom doors when entering. The lunchtime meal was observed and staff were seen to support those residents who needed assistance in a dignified manner. A handover between staff was observed. Staff were heard to be courteous towards the residents and their needs. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 15 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): 12,13,14,15 The quality outcome in this area based on available evidence is good. Residents are offered a variety of group and one to one activities inside and outside the home. Visitors are made welcome. Residents are offered choice but this is not always recorded on the plan of care. The home offers a variety of home cooked food, which is above the minimum standard expected. EVIDENCE: A discussion was held with the activities organiser and the rota that was displayed was viewed as well as a diary. The rota showed that three different activities are happening most weekdays. Morning activities tend to be one to one activities such as nail care and the sweet trolley with a focus on group activities in the afternoon. Afternoon activities include Darts, quizzes, painting and bingo. Examples of evening activities include Film shows, Cards, Dominoes etc. On the day of the visit nine residents were viewed taking part in the painting class. This appeared well organised with a variety of activities on offer according to ability. The activities organiser keeps a daily diary, which was viewed. This includes resident’s response to new activities tried and who undertook which activities. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 16 It also showed that the activities organiser carries out personal shopping for some residents as requested. The diary also showed that activities such as “master chef” and birthday parties also occur within the home. Two residents confirmed that they enjoy the activities on offer. Both participated in some of their own choice. They stated that the activities organiser comes to see them in the morning to let them know what’s happening that day. On the day of the visit one resident was getting ready to visit the local library. Whilst there he had offered to collect books for another resident who enjoys to reading but didn’t feel well enough to visit the library himself. This resident was hoping to do this himself at a later date. Both of these residents confirmed that they are free to come and go as they please Records showed that in recent months pub lunches have taken place in Southport and a shopping day. One resident is supported to go home on a weekly basis. The home shares a minibus with the sister home for trips out. A barge trip occurred last month. The activities organiser explained that she aims to provide three “big” trips out a year with smaller trips to local garden centres etc in between and one to one support for those who wish to visit the local shops. A relative confirmed that she is free to visit whenever she pleases and that she found the relatives room of great benefit. Viewing the visitor’s book showed that visitors arrive at a variety of times through out the day. Two care plans were viewed. One contained evidence of preferences such as preferred washing and bathing, chosen hairstyles makeup etc. The other contained very little. A discussion was held with the manager and one resident. Residents meetings are held regularly and the manager is invited at the request of the residents when they think it is appropriate. During discussions with two residents they confirmed that choice is offered. Staff were overheard to offer choice around any activities that they were supporting the residents with. The lunchtime meal was observed. Menus were viewed and discussions took place with three residents and the cook. The cook should be commended on the provision and presentation of food served within the home. Menus showed that a variety of home cooked food is offered at each mealtime. Cheese and biscuits and fruit are offered after every meal following desert. Residents are consulted about forthcoming meals and supported to make choices. The cook keeps records of choices made which were viewed. The cook meets with all new residents who come into the home to discuss preferences, needs and choices. Discussions showed that she is experienced in specialised diets. Moulds were viewed which are used for semi solid diets. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 17 This ensures that the food has the same appearance as if it was solid but has a soft consistency for those residents who have swallowing difficulties. The lunchtime meal was relaxed. Staff supported residents appropriately. A relative was observed assisting one resident to eat. Staff ensured that the relative was comfortable with the procedure. The main doors to the dining room were closed so that the amount of noise was reduced which helped to promote a calm atmosphere. Those residents, who required, were wearing appropriate protective clothing. The tables were set nicely with condiments and sprig vases. The cook explained that she frequently purchases one off special items for those residents who” fancy something special”. Examples were given of steak, smoked salmon etc. Discussions with two staff confirmed this to be true. The service employs a dining room assistant who asks residents after every meal whether they enjoyed the food or not. This information is fed back to the cook who acts accordingly. Discussions were held with three residents who spoke extremely positively about the food served within the home. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 18 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 18 The quality outcome in this area based on available evidence is good. Residents and relatives concerns are listened to and acted on. Staff have the skills and knowledge to protect vulnerable residents from abuse. EVIDENCE: This section was assessed during the visit to Greenheys ten days previously. The evidence gathered was as follows: Minutes of meetings and a discussion with the manager evidenced that relatives meetings were held every quarter at the relative’s request. The manager agreed that this was used as a vehicle for small concerns. As the manager is responsible for two sites and the head office for the organisation is based off site, the manager completes a “ movement” sheet so that relatives are aware of where she is during the day. Discussions with one relative and two residents at Kemp Lodge evidenced that they believed that they could approach the manager at any time and that they felt as though she listened to their concerns and acted on them. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 19 Since the last visit all staff have undertaken training on Protection of Vulnerable Adults. The organisation has a comprehensive policy on abuse awareness and staff also have access to the local guidelines on what to do if they suspect abuse has occurred. This is held in the main office. Since the last visit the manager identified a potential abuse situation in another home and referred this to the police, which was eventually unfounded. The manager dealt with the concerns appropriately and cooperated with both the police and Social Services until the situation was resolved. The manager also ensured that CSCI were aware of the situation by completing a regulation 37-notifiable incident form. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 20 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, 26 The quality outcome in this area based on available evidence is good The home is a clean comfortable place to live. EVIDENCE: A tour of the environment was undertaken. A discussion with the manager and the maintenance officer revealed that the home has an ongoing programme of redecoration. No areas were identified as being in need of redecoration on the day of the visit. All areas appeared tidy and homely with good quality fittings and furnishings. Three bedrooms were viewed. Each was homely and contained many personal possessions of the occupier. The home has three lounges one of which is used as a quiet lounge. Smoking is permitted in this lounge only. The home benefits form having a relative’s room. This contained tea and coffee making facilities and useful information about the home and forthcoming events. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 21 The home presented as a clean comfortable place to live. On the day of the visit it smelt pleasant and was warm. The home scored 92 following an internal audit recently for housekeeping. Three domestic staff are employed who work, thirty-two hours (two staff) and thirty seven and half hours (one staff). A full time housekeeper is also employed. Since the last visit the service has developed a housekeeping book. This covered all areas and included photographs of areas that had been cleaned and tidied so that all staff would be aware of the standards expected by the service. The laundry room was viewed. This was found to be clean and tidy with clean linen being stored separately from dirty. Staff have supplies to deal with foul linen and hand washing facilities and liquid soap were available. . The laundry was fitted with industrial washing machines and dryers Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 22 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): 27,28,29,30 The quality outcome in this area based on available evidence is good. Staff are employed in greater than expected numbers to meet the residents needs. The service employs greater than the expected level of staff who have achieved NVQ or equivalent qualifications. Robust recruitment procedures exist which help to protect vulnerable residents. Staff have had training to meet the residents needs. EVIDENCE: Off duties were viewed which showed that generally eight staff are available from 8 am until 4pm and five staff from 12 midday until 8 pm. This gives an overlap of shifts for four hours and is greater than expected for a home of this size. hree waking night staff are available each night and at times this rises to four. Professionally qualified nurses are available 24 hours a day. A discussion with the manager and viewing staff files and training records showed that two staff are working towards achieving an NVQ qualification in care. All other staff employed have already achieved this qualification or have achieved an equivalent qualification. This is greater than the expected 50 suggested in the national minimum standards. Three staff files were viewed. Each contained the necessary information required by the Care Home regulations 2001. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 23 During the recent visit to the sister home, a discussion was held with the manager. An on line induction programme has been introduced since the last inspection. This enables new staff to learn their role at their own speed. The induction appeared thorough and covered organisational policies as well as mandatory training . The manager is able to access staff portfolios on line so she is able to monitor staff progress. New staff are given supernumerary time on a weekly basis whilst they undertake this training. Training files were viewed which showed that staff have undertaken a variety of training since the last inspection. This included training on administering thicken fluids, moving and handling, Cardiac Pulmonary Resuscitation, Abuse awareness, Fire prevention, Protection of Vulnerable Adults Awareness, mentorship training, phlebotomy, Diabetic foot care, Psychosocial intervention, and falls risks assessment. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 24 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): 31,33,35,38 The quality outcome in this area based on available evidence is good The manager is fit to manage and manages the service well. The service consults representatives but doesn’t always inform CSCI of outcomes. Service users monies are safe. The service acts responsibly in maintaining Health and safety. EVIDENCE: During the recent visit to the sister home, a discussion was held with the manager and her application to be the registered manager with CSCI was viewed. The manager was unaware of the need to keep a file on the premises that would prove her “ fitness “ to manage the service. She explained that the Head office of the organisation would hold information of this nature. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 25 A requirement was made in relation to this following the visit therefore this requirement has not been repeated in this report. Viewing the application showed that the manager is a qualified nurse who has undertaken further training since achieving registered nurse status. This included BA Health care management, Diploma in the care of Older People, Certificate in Dementia Studies and several ENB qualifications in continence care, and care of older people. The manager has also achieved awards enabling her to assess NVQ candidates and has past experience of managing care homes. Discussions were held with two relatives and two members of staff. All commented positively on the manager’s abilities. It was evidenced that all requirements made following the last inspection had been addressed. A discussion took place with the manager regarding quality assurance. The responsible individual undertakes regulation 26 visits and copies of these were viewed. The manager has introduced audits covering medication management, care planning and health and safety. Quarterly relatives meetings are held for consultation. The organisation sends out a yearly survey to relatives, residents and staff. An external source correlates the information from the surveys into a report and action plans are developed from these where appropriate. The manager was unaware of the need to send CSCI a copy of this document. The service has had outside quality assurance assessments undertaken and one had been performed prior to the visit. The outside of the building showed that five stars were displayed and the manager explained that this is the highest level achievable under this system. Documentation relating to residents personal allowances and the homes accounting system was viewed. The service provides support to a small number of residents who require support with finances. A discussion was held with the manager. The manager explained that she carries out audits on resident’s personal allowances and associated paperwork and a copy of the most recent audit was viewed. The records viewed were clear and contained details of income and expenditure. The manager explained that small amounts of money are provided by families who are appointee so that residents have access to some money at all times. The manager and administrator confirmed that resident’s personal allowances are kept in an interest bearing account, which is separate to the organisations accounts, and residents receive interest proportionally. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 26 The manager explained that the organisation operates a cold harbour computer system so up to date statements can be obtained for residents at any time. A tour of the environment was undertaken and no concerns relating to health and safety were identified. It was evidenced that past requirements relating to Fire safety had been addressed. The home has a fire risk assessment and this was viewed but will require reviewing in the near future. Copies of weekly audits were viewed which are used to monitor Health and Safety within the home. These had been developed further to include areas of maintenance, which required attention such as redecoration. Records were viewed which showed that the fire alarm is tested weekly to ensure it is working. Staff attended fire lectures at the end of last year as part of their mandatory training. A discussion with the maintenance officer showed that practice evacuations have occurred in the past but that these have not happened for some time. This was also identified during the visit to the sister home therefore this requirement has not been repeated. Records showed that water temperatures are randomly tested to ensure temperatures remain at a safe level and maintenance is undertaken to ensure that the water system is cleansed. A decorating schedule was viewed which identified works so far and outstanding works still to be completed. An emergency response file was viewed which covered actions to be taken and people to be contacted in all emergency situations including outside contractors. Contracts were viewed which showed that hoisting equipment is serviced regularly. Portable appliance testing was carried out in March 2006 and up to date stickers were viewed on small electrical appliances. Copies of contracts for disposal of clinical waste and pest control were also viewed. An up to date NICEIC and gas safety certificate was viewed which showed that both supplies have been tested for safety. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 27 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 4 28 4 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 2 Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 28 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 OP7 Regulation 15. - (1) Requirement Timescale for action 31/12/06 2 3 OP8 OP8 12. - (1) (a) 12. -(1) (a) 13. - (1) (b) The manager must ensure that staff complete all necessary information required in care plans including how residents are to be supported with social activities. Risk assessments must be 30/11/06 updated to match the residents changing needs Staff must record changes in 30/11/06 wound care by either photographs or wound mapping 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 OP7 OP7 OP9 Good Practice Recommendations All Residents or representatives should be involved and consulted about their care plans Care plans should be regularly audited to promote consistency Staff should be reminded to sign when administering DS0000017245.V302278.R01.S.doc Version 5.2 Page 29 Kemp Lodge 4. 5 OP9 OP14 creams Photographs of each resident should be available to reduce the risk of a mistake occurring Staff should be reminded to record all residents’ personal choices on the plan of care. Kemp Lodge DS0000017245.V302278.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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. 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