Inspection on 21/12/05 for Kesteven Grange

This inspection was carried out on 21st December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kesteven Grange 17/11/08

Kesteven Grange 15/11/07

Kesteven Grange 09/11/06

Kesteven Grange 11/08/05

Kesteven Grange 09/11/04

Kesteven Grange 06/07/04

Kesteven Grange 11/03/04

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Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Kesteven Grange Kesteven Way Kingswood Kingston upon Hull East Yorkshire HU7 5EY Lead Inspector Janet Lamb Unannounced Inspection 21st December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kesteven Grange DS0000031929.V273350.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. Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kesteven Grange Address Kesteven Way Kingswood Kingston upon Hull East Yorkshire HU7 5EY 01482 837556 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) Southern Cross Care Homes No 2 Limited Position Vacant Care Home 54 Category(ies) of Dementia - over 65 years of age (54), Old age, registration, with number not falling within any other category (54) of places Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit four named service users, aged under 65. Date of last inspection 11th August 2005 Brief Description of the Service: The home is registered to provide personal care and accommodation for 54 people of either gender over the age of 65, some of whom may also suffer from dementia. This also includes up to 4 people under the age of 65. Kesteven Grange is a purpose built home situated on a large residential estate on the northern outskirts of the city of Hull. The home has 46 single and 4 double bedrooms. Four bedrooms have ensuite facilities (toilet and wash hand basin). There is a large lounge and separate dining room on the ground floor and a large lounge/dining room on the first floor. There are a number of bathrooms and toilets throughout the home and a passenger lift to access the first floor for service users unable to use either of the two stairways. Office accommodation, the kitchen and laundry are all on the ground floor. Outside is a large lawned garden and an enclosed seating area for service users to enjoy the good weather. Regular bus services stop near the home and local community facilities are a short drive away. The home has a large car park for visitors. Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection, the second of two to be carried out in each inspection year, took approximately 6½ hours to complete. It involved interviews with three residents, the Manager and Administrator, inspecting some of the home’s records and documents and viewing some of the home. Other residents were also briefly spoken to. What the service does well: 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. Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 6 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 Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 7 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): These standards were not assessed at this inspection. EVIDENCE: Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 8 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): These standards were not assessed at this inspection. EVIDENCE: Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 9 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 only. Residents in the special unit on the upper floor now enjoy improved activities and pastimes. EVIDENCE: Residents were observed to have more opportunities in respect of activities and pastimes. Staff have improved their efforts to provide these and have also made the environment more homely. The unit was also considered to be cleaner and fresher than at the last inspection. Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 10 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): These standards were not assessed at this inspection. EVIDENCE: Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 11 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 only. Residents live in a safe and well-maintained environment. EVIDENCE: The home is located on a busy road on a development to the north of the city of Kingston Upon Hull, but security is good. Keypad locks are in use both to the exits and on internal doors to service areas. The Manager intends to have these fitted on doors to stairways as well, to reduce risks to some residents who wander. There is a maintenance man who sets and follows a routine programme of maintenance and redecoration and completes repairs as they arise. Rooms are redecorated as they become empty and several have been done since the last inspection. The grounds are pleasant but very open, except for a small area with fencing, and none are accessible to residents that are confused, therefore there are plans to take a small area of the side car park to create an enclosed safe garden. Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 12 Fire and environmental health department requirements are met. Residents spoken to felt secure in the home, expressed they often use the main entrance porch area to sit in, and talked about going on outings with the home’s entertainment coordinator. Residents were observed using the porch. Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 only. Residents are in safe hands at the moment, and this will improve further with the completion of NVQs. EVIDENCE: There has been a major drive since the last inspection, to have all care staff complete the NVQ level 2 and all but two night carers are now doing the award. Staff are at different stages of the award, but the minimum ratio of 50 should soon be achieved. Staffing vacancies identified at the last inspection have now been filled. Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Residents live in a home that is well run and in their best interests. Their financial interests are well protected and their health, safety and welfare are well promoted and protected. EVIDENCE: Residents do not yet have the benefit of a Registered Manager, but the candidate for this position and currently managing the home has been a Registered Manager with the CSCI of a domiciliary care service. She has an NVQ Level 4 in Management, a NEBS Certificate in Management, still requires an NVQ Level 4 in Care, and has more than two years in a senior management capacity. An application for the registration of the Manager is now required. The Manager has begun to implement a quality assurance system and monitors several areas of the service provided to residents for purposes of improving it. She has held residents’ meetings and ‘surgeries’ to seek views Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 15 on how residents would like the home to run, and has made enquiries with Hull City Council Social Services Department to seek their quality development scheme award. She has also received information and assistance from the Manager of a sister home to become familiar with quality assurance documentation expected by Southern Cross, the new Registered Provider. There are several files held containing monthly monitoring audit sheets on areas such as accidents, complaints, medication administration, staffing, personal care, etc. Other documents are also available showing the levels of quality monitoring within the service. The quality assurance systems in place have not yet been reviewed and reported on as required in regulation 24(2) and this should be the next step. Residents spoken to were not aware of quality assurance systems, but are satisfied their individual and group needs are addressed daily and that their personal review is the best medium to make formal requests. Some speak up daily for themselves and others. Some residents still consider they are living in the home but do not have the right to make requests, seek changes, or even hold control over their personal documentation. They expressed it was the responsibility of the management to allow the Inspector to view their files. One resident expressed some very strong views about their personal situation, which following permission to do so, the Inspector passed on to the Manager. Generally residents were satisfied with their personal financial arrangements. Evidence was seen of the systems used to handle residents’ finances and to safeguard them from financial abuse. Evidence was also seen of the maintenance safety monitoring work undertaken in the home. Responsible maintenance work is completed either by the home’s handyman or contracted specialists and records are well maintained. Health, safety and welfare of residents and staff are safeguarded. Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? Yes. 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. 2. Standard OP20 OP31 Regulation 13 and 23 8 and 9 Requirement External grounds must be accessible, suitable for, and safe for use by all service users. The Registered Provider must submit an application to register the Manager, who must have enrolled on NVQ Level 4 in Care qualificfation within the timescale. Timescale for action 30/06/06 31/03/06 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 Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kesteven Grange DS0000031929.V273350.R01.S.doc Version 5.0 Page 19 - 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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