Inspection on 31/07/07 for Kernow House

This inspection was carried out on 31st July 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

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 Kernow House Landlake Road Launceston Cornwall PL15 9HP Lead Inspector Diana Penrose Unannounced Inspection 31st July 2007 10:30 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 Kernow House DS0000069233.V341967.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. Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kernow House Address Landlake Road Launceston Cornwall PL15 9HP 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) 01566 777841 01566 777843 Barchester Healthcare Homes Ltd Mrs Valerie Baggott Care Home 98 Category(ies) of Dementia - over 65 years of age (43), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (43), Old age, not falling within any other category (28), Physical disability (27), Physical disability over 65 years of age (28) Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 8. Service users to include up to 28 adults of old age (OP) accommodated in Caradon Unit. Service users to include up to 28 adults with a physical disability (PD)(E) accommodated in Caradon Unit. Total number of service users to be accommodated in Caradon Unit not to exceed 28. Service users to include up to 43 adults aged over 65 years with a mental illness MD(E) accommodated at Petherwin Unit, of which 5 may be between the ages of 55 and 65. Service users to include up to 43 adults aged over 65 years with Dementia DE(E) accommodated at Petherwin Unit, of which 5 may be between the age of 55 and 65. Total number of service users accommodated in Petherwin Unit not to exceed 43. Overall total number of service users not to exceed 98. Service users to include up to 27 adults with physical disability (PD) in Millaton Court. 04/10/06 Date of last inspection Brief Description of the Service: Kernow House is part of the Barchester Healthcare group of homes. It is a relatively new building, purpose built to provide nursing care and accommodation for up to 98 people. The accommodation is divided into three units Caradon unit can accommodate up to 28 elderly frail people, Petherwin unit up to 43 elderly people with dementia (five maybe between 55 and 65 years of age) and Millaton Court unit 27 people with a physical disability (presently all of whom have Huntington’s Disease). The home is situated on the outskirts of Launceston near the Health Centre & hospital. The home is built on two floors, which are connected by shaft lifts (for passengers & goods) and stairs. Caradon unit is on the ground floor, Petherwin unit is upstairs and Millaton Court is a separate single storey wing. Accommodation is mainly in single en suite rooms although there are a number of doubles within permitted limits. There are sufficient lounge facilities on each unit. Meals are cooked in the ground floor kitchen; there are satellite kitchens upstairs and on Millaton Court. The home has adequate dining facilities. Exit & Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 5 entrance doors are protected by keypads to ensure the safety of people in the building. There is a small patio accessible to residents outside the Caradon dining room, a sensory garden between Caradon and Millaton Court and separate garden area at Millaton Court. There have been recent improvements to the gardens and there are further plans for the future. There is sufficient car parking available for staff and visitors. Qualified Nurses and Care Assistants provide care within a friendly atmosphere. Activities take place each day organised by activities co-ordinators. Information about the home is available in the form of a residents’ guide, which can be supplied to enquirers on request. A copy of most recent inspection report is available in the home. Fees across the whole home range from £650 to £1953 per week; this information was supplied to the Commission on 10/08/07. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors visited Kernow House Nursing Home on the 31 July 2007 and spent eight and a half hours at the home. This was a key inspection and an unannounced visit. It was the Commissions first inspection of Millaton Court. The purpose of the inspection was to ensure that the needs of people using the service are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that placements in the home result in good outcomes for people. All of the key standards were inspected. On the day of inspection 84 residents were living in the home. The methods used to undertake the inspection were to meet with a number of residents, relatives, staff and the managers to gain their views on the services offered by Kernow House Nursing Home. Records, policies and procedures were examined and the inspectors toured the building. This report summarises the findings of this inspection. Residents expressed satisfaction with the care and services provided at the home. Staff morale appeared good and there were sufficient staff on duty. Overall the home is providing a good quality of care to the residents placed there. What the service does well: The service is well managed and the company strives for quality. The home is spacious and provides a warm, safe environment for the people using the service, staff and visitors. The home is clean and free from offensive odours. People spoken with were happy living in the home and had their own possessions around them. One said she had settled in and felt safe. People are assessed prior to moving in and information from outside agencies is obtained where appropriate. The people using the service have a written care plan that is used to inform and direct staff in the care to be provided. Relevant risk assessments are undertaken and daily records are kept. Nutritional needs are assessed and a varied menu is on offer, everyone said the food provided is very good. Residents said their healthcare needs are met and the staff look after them well. Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 7 There is a medicines policy and system in place for the ordering, storage, administration and disposal of medicines. A qualified nurse administers the medicines at all times. There is a satisfactory complaints procedure that ensures complaints are dealt with promptly and there are systems in place to safeguard residents from abuse. Recruitment processes are generally good. There are sufficient numbers of staff on duty and people using the service said the staff are kind and caring. One person confined to bed said, “ the staff are lovely, they come in frequently, or when I call and they make sure I am comfortable”. Training is taken very seriously; there is an induction programme for new employees and an excellent training and development programme for staff. The training officer has excellent systems in place for recording training and showing when further sessions are needed. Staff said that plenty of training is on offer and a great deal is provided in the home. Regular meetings take place and staff feel supported in their roles. There are quality assurance systems in place and the Company is continually trying to improve the service. Residents meetings take place and people feel they can air their views. Health and safety is taken seriously and external audits take place. What has improved since the last inspection? What they could do better: Some information on assessment forms was very clear but some could be more detailed and the form should state from where the information was gathered. Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 8 The care plans should be compiled prior to admission and need to be fully detailed, consistent with information easy to locate. All handwritten instructions on medicine charts should be witnessed and signed by two staff, the manager said this would be addressed Deployment of staff in some areas needs to be addressed and was discussed with the management team. Recruitment records need to be kept up to date to ensure all documents are available for inspection. 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. Kernow House DS0000069233.V341967.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 Kernow House DS0000069233.V341967.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 is not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are only admitted to the home following an assessment of their needs to ensure the home can provide suitable care. EVIDENCE: Evidence was provided in the form of records and interviews with residents and the registered manager. The registered manager, deputy manager or one of the unit managers visits prospective residents prior to admission. Out of county assessments are sometimes carried out by a manager from a Barchester home nearer to the person requiring assessment. Information from Adult Social Care and hospital staff is obtained where appropriate. Forms inspected were completed dated and signed, some information was very clear but some could be more detailed and the form should state from where the information was gathered. This was fed back to the management team. A further assessment is undertaken on Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 11 admission to the home and an individual plan of care is compiled from these assessments. Kernow House DS0000069233.V341967.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are generated for each resident to inform and direct the staff in the care provision. These should be compiled prior to admission and need to be fully detailed, consistent with information easy to locate. Residents have access to health care services as necessary to ensure their assessed needs are met. There are systems and policies in place for dealing with resident’s medicines that assure their safety. Systems are in place to ensure that residents are respected and their privacy is upheld at all times. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and talking with the people using the service, visitors, managers and staff. Each person using the service has a written care plan that provides information to direct staff in the care to be provided. Care plans are not compiled and put Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 13 in place prior to admission, and this requires improvement. This was discussed with the management team who agreed to change the practice in this area. In general the care plans inspected outlined the persons needs and provided advice and guidance for staff. Some elements require more detail to fully direct staff and care needs to be taken when writing the plans, as some information was conflicting. Some of the files were disorganised and it was difficult to find the relevant information. One plan included forms of restraint but there was no assessment or explicit guidance for staff. Staff did not appear confident managing this person although they had received training in the management of challenging behaviour. These issues were discussed with the management team. Some of the people using the service have a life history included in their file and it is intended to get these for all residents. Care plans are reviewed monthly and changes are recorded. Risk assessments are included and reviewed. There is some evidence that care plans are compiled with the resident or representative and signed. Daily records are maintained and both nurses and care staff write these, the information is variable. Care practice was observed to be appropriate during the inspection and carried out in a calm, efficient manner. People spoken with said their needs are met and the staff are kind and caring. The inspectors were told that doctors and other healthcare professionals visit as appropriate and records were seen to support this. The registered manager said that the home has very good links with the medical centre. Some of the nurses specialise in specific subjects and link with external agencies to remain up to date The home has plenty of equipment for moving and handling and pressure relief. Slide sheets used are individually named and some hoist slings are individual, those shared are only used for people who are clothed. A new stand aid was shown to the inspectors. Hospital style beds are provided where needed. There is a corporate policy and a local policy for the administration of medicines. There is a policy for self-administration but no residents were doing so at the time of the inspection. Medicine reference books and relevant guidelines are available to staff. Storage of medicines is safe and secure. Only qualified nurses administer medicines but care staff may witness administration and sign the controlled drug register. Medicines received into the home are recorded and signed for on the medicine administration charts. Some handwritten instructions have not been signed by two staff the manager said this would be addressed. Controlled drugs are stored and recorded appropriately. Medicines are disposed of via a waste disposal company with records maintained. The registered manager said that all care staff are in the process of having basic medication training, those on induction have commenced this first. The home is changing their supplier soon and staff said they have received training from the new supplier. Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 14 All staff receive training in promoting values, individuality, privacy and dignity. Residents’ privacy was observed to be upheld during the inspection and staff knocked on doors before entering. People using the service said that staff are respectful and uphold their privacy. Shared rooms are provided with appropriate screens. Kernow House DS0000069233.V341967.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities and aims to offer a lifestyle that meets individual residents needs. Links with family, friends and the community are good and allow residents the opportunity to socialise. Residents are helped to maintain control over their lives and staff respect their individual preferences and choice. Dietary needs of residents are well catered for with a varied selection of food available that aims to meet their taste and preference. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and talking with the people using the service, visitors, managers and staff. Activity co-ordinators are employed to organise activities on each unit; people can choose whether or not to join in. Activities are recorded in the care folders. New documentation is being implemented and the training for this is taking place very soon. There is one to one social interaction with the people using the service and this was observed. There were activities taking place on the day of the inspection. There was a singer on Caradon unit and both residents Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 16 and staff were joining in. One resident said he enjoys the activities, he said “the singing is good and even the managers join in”. Some people were in the garden at Millaton Court and had compiled a poem that was written on a blackboard. The unit manager of Millaton Court said she has re-organised and improved activities on the unit. The home has sufficient transport for taking people out on trips and to the local community. One person told the inspectors she was going out to the swimming pool. The daily routines are flexible some people told the inspector that they choose when they get up and go to bed. They said they choose what clothes to wear and how they spend their day. They said they receive visitors when they wish and can receive them in private, one visitor said she visit’s when she likes and is always made very welcome. The visitor’s book showed that people visit the home. The menu shows there are plenty of choices at mealtimes. Residents have a nutritional needs assessment using the Malnutrition Universal Screening Tool (MUST) and likes and dislikes are individually recorded. There is a varied menu that that has recently been changed. The menu includes finger food and a selection of puddings; fresh fruit and vegetables are included every day. Meals are served in the dining areas or individual bedrooms. Some people from Petherwin unit come downstairs to dine on the Caradon unit. Meals are very well presented and appropriate assistance is given in a relaxed manner. People enjoyed the lunchtime meal. Comments were very positive in respect of the food provision and people said there were choices that met their personal preferences. The Company has their own Chef Academy providing staff training. Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that ensures complaints are listened to and acted upon. Arrangements are in place for the protection of residents safeguarding them from harm or abuse. EVIDENCE: Evidence was provided in the form of documentation, records and discussion with the registered manager. There is a suitable complaints policy in the home that is available to staff and residents. There is a method for recording complaints, the action taken and the outcome. There have been no complaints since the last inspection. There have been six complaints to the home dealt with by the registered manager and recorded. Two of these were upheld. There have been concerns from one individual raised with the Commission that have been investigated during this inspection and partially upheld. There is an appropriate adult protection policy that includes the local inter agency procedures. All staff receive in house adult protection training that includes a video. There is a secure facility for the storage of money in the home. Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 18 Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 19 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, 21 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home and grounds are well maintained providing a safe environment for residents, staff and visitors. The home is clean and free from offensive odours making it a pleasant place to live in. EVIDENCE: Evidence was provided in the form of a tour of the building, talking with the people using the service, visitors, managers and staff. The home is warm, homely and clean with no offensive odours. It is decorated and furnished to a high standard with an ongoing maintenance and refurbishment programme. Special aids and equipment are provided where necessary. Millaton Court has an environment set up to meet a wide range of needs for people who are physically disabled. The layout of Petherwin unit does not lend itself to the user group and was untidy in some areas. It is also less Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 20 homely and less personalised than the other units. Residents spoken with said they are happy with their rooms and the facilities provided. One person said he has some of his own furniture with him. The grounds are tidy and some areas are accessible to residents; there is a small sensory garden to the rear of Caradon Unit, a patio outside the dining room on Caradon unit and a garden at Millaton Court. The registered manager showed the inspectors an area at the front of the home that she hopes will be converted into a garden for the people using the service. The registered manager said that bathing facilities have been reviewed and the bathroom used for storage at the last inspection is now in use, although rarely used. All laundry is dealt with in house and the system seems to work well. A number of clothes that are unmarked are being left outside the Caradon dining room for a short period to allow residents, staff and visitors to look at them and see if they can identify whom they belong to. There are adequate sluices with washer disinfectors. Hand-washing facilities are appropriate and staff were observed wearing disposable gloves and aprons. Infection control training takes place in house and the home has a suitable policy. Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are suitable for the number of people using the service and staff morale is good. Deployment of staff in some areas needs to be addressed. People using the service are in safe hands and they benefit from the 45 of care staff trained to at least NVQ level 2 in care. Recruitment procedures are robust and offer protection to the residents; record keeping needs to be kept up to date. The home provides excellent training for staff to help them be more competent in their roles. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and talking with the people using the service, visitors, managers and staff. Each unit has a manager in charge; there is also a qualified nurse on duty at all times with a team of care assistants. The deputy manager stated that sometimes Caradon unit has two nurses on duty and one less carer. The ratio on Millaton Court is one carer to two residents. Deployment of staff on Petherwin unit could be improved to ensure people using the service are adequately supervised. The registered manager said the home has a full quota of staff at the moment and there appeared to be enough staff on duty during the inspection. The home has it’s own bank of staff to cover sickness and Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 22 annual leave and so on, the registered manager said that agency staff have not been required since January 2007. The management appropriately supports the 45 of overseas staff employed and good efforts are made to improve communication skills. Staff were observed to interact very well with the people using the service, in a kind, relaxed manner. Care practice observed was appropriate and safe. A person using the service on Millaton Court said she was assisted to settle in and feels safe with the staff. The staff appeared more focussed on Petherwin unit than at the last inspection, however there were still occasions when staff were wandering around with no apparent goal. There was less interaction with the people on this unit and some were watching television, not engaging with the people using the service. 45 of care staff have an NVQ either at level 2 or 3 or are qualified nurses from overseas. Ten care staff are undertaking NVQ courses and copies of NVQ certificates are kept on file. There are eight NVQ assessors employed in the home. Four personnel files were inspected and contained most of the records required by legislation. Not all had two references and it appeared that two people had commenced work prior to a satisfactory POVA first check being obtained. The registered manager has since located the checks that had been received in time. She said there is a new policy that states that all new members of staff who commence work with a POVA first check prior to CRB clearance, have to sign a form to agree to work supervised at all times and these had been signed. A copy of any relevant qualification certificates are held with the person responsible for training in the home. Registration with the Nursing and Midwifery Council is confirmed. Interview records were only seen on one file, the registered manager said she would make sure there are interview records for all new employees in future. All staff have terms and conditions of employment The person responsible for in house training is very motivated in her role and has robust systems in place. She is qualified to train staff in several subjects and undertakes regular update training; at present she is undertaking an NVQ level three dementia course. She is also an NVQ assessor. Specific training sessions are held for overseas staff and the general social care council code of conduct is available in a variety of languages. The registered manager and deputy manager are involved in some training sessions. Records are maintained on a computer and show when individuals attend training it also identifies when training is due. The files are backed up to the company’s head office. Staff sign a sheet of attendance at sessions and are asked to complete an evaluation form. The teaching session plans are kept for Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 23 reference and questionnaires or quizzes are used to ensure staff understand the content of the training. Staff receive a certificate for all training they do in house and copies are held in the home. The company has a clinical development nurse who is responsible for updating the nurses in the documentation used and medications. First aid training is provided by Pinnacle and sometimes external courses are attended. There are computer training programmes in place for health and safety, food hygiene and customer care. New employees have an induction booklet to work through with their mentor with three and six month development checks. New staff are also given a booklet to work through titled “my career development with Barchester” The induction programme adheres to the Skills for Care guidelines. The booklets are kept with the individual employee and none in use were seen during the inspection. Staff said there is plenty of training available and they are encouraged to attend. They said they are reminded when statutory training is due. Kernow House DS0000069233.V341967.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is a person of good character and fit to run the home. A deputy manager and three unit managers support her. The home is run in the best interest of the residents and they benefit from the Quality Assurance systems in place. There is a suitable system in the home for dealing with residents’ money that ensures that the residents’ financial interests are safeguarded. Appropriate training and safety checks are undertaken to ensure the health safety and welfare of residents and staff. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and talking with the people using the service, visitors, managers and staff. Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 25 The registered manager is a registered general nurse who has completed the Registered Managers’ Award. She said she keeps herself up to date through training provided by Barchester’s Learning and Development Academy and relevant external training providers. A deputy manager and three unit managers support the registered manager. People using the service said the management team are approachable and they feel the home is run well. All staff spoken with felt supported by the management team. They said they could go to the registered manager at any time if they have a problem. Quality assurance systems are in place. This includes an annual survey to ascertain the views of the people using the service and their representatives. Various audits take place and there are files of evidence that relate to the National Minimum Standards. An external health and safety audit has been very positive. The Regional Director visits the home every month, as part of the visit she undertakes an inspection of the service and completes a report to comply with Regulation 26. These need not be sent to the Commission but must be stored in the home. There are staff and residents meetings held and minutes are kept. Staff and residents said they are able to air their views. There is a policy and system in place for the management of resident’s money. There are only a few people with money in the residents account and this is managed well. This system is being phased out, as money is not being held for the people using the service. They are invoiced for purchases and services such as hairdressing and chiropody. Individual records are kept on a computer and statements can be printed for the resident or their representative. Each unit holds an amount of petty cash, which is used for purchases and receipts, are maintained. There are health and safety policies and procedures in place to promote safe working practices. Staff receive statutory training regularly. There is a person trained in first aid on duty at all times. The kitchen staff have all received food hygiene training. There are a range of environmental risk assessments that have been reviewed and individual risk assessments for residents. There is a health and safety steering group who meet regularly, minutes are maintained. COSHH data is available to staff. Accident recording is appropriate but there needs to be a robust review of the reporting arrangements for staff. Fire safety policies are in place and guidance is available to staff. Service and equipment checks are undertaken with records maintained. Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 26 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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 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 2 28 2 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kernow House DS0000069233.V341967.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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