Inspection on 18/04/06 for Kestrel House

This inspection was carried out on 18th April 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kestrel House 06/10/09

Kestrel House 14/04/09

Kestrel House 15/04/08

Kestrel House 23/05/07

Kestrel House 17/10/05

Kestrel House 10/05/05

Kestrel House 08/11/04

Kestrel House 25/05/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Kestrel House 220 Willingdon Road Eastbourne East Sussex BN21 1XR Lead Inspector Debbie Calveley Key Unannounced Inspection 18th April 2006 08:00 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 Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 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. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kestrel House Address 220 Willingdon Road Eastbourne East Sussex BN21 1XR 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) 01323-431199 01323-649420 ANS Homes Limited Debra Mary Potter Care Home 54 Category(ies) of Old age, not falling within any other category registration, with number (54) of places Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is fiftyfour (54). Service users must be older people aged sixty-five (65) years or over who are chronically ill and in receipt of NHS Continuing Care Services. To provide care to service users aged between eighteen (18) and sixty-five (65) years who are chronically ill and in receipt of NHS Continuing Care Services. 17th October 2005 Date of last inspection Brief Description of the Service: Kestrel House is owned and managed by Associated Nursing Services (ANS), which is a subsidiary company of B.U.P.A. Kestrel House was purpose built in 1996 to accommodate fifty- four relocated patients that had been cared for in a local National Health Geriatric hospital. All service users living in this home have been assessed as meeting the eligibility criteria for continuing care and are funded by the PCT. The accomodation comprises of forty-eight single bedrooms with ensuite facilities and three double rooms. There is ample communal space, which have recently been upgraded. Kestrel house is situated on the A22, and approximately 1-½ miles from Eastbourne town centre. There is car parking on site at the front of the home and a small garden and patio area is situated to the rear and side of the home. The service provides all service users with a copy of the service users information pack and a brochure as part of the admission process. Copies of inspection reports and the homes Statement of Purpose are available in the reception area of the home. Fees charged as from 1 April 2006 in accordance with the contract with the Primary Care Trust is £568.48, which includes toiletries. Additional charges are made for hairdressing, chiropody, newspapers and outside activities. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over two consecutive days and totalling 16.5 hours. There were 46 service users in residence, of which six were case tracked and spoken with. During the tour of the premises twelve other service users of both sexes were also spoken with. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including care plans, medication records, training records and recruitment files. Seven members of care staff, four trained nurses, the activity co-ordinator and the cook & kitchen assistant were spoken with in addition to discussion with the Registered Manager and three visiting health professionals. Comment cards received from four service users and five relatives were generally positive and that both groups were satisfied with the services provided. What the service does well: What has improved since the last inspection? The pre-admission care assessment is now carried out for all new admissions enabling the home to demonstrate it can meet service users needs. The improvements to the care plans have been maintained and were found to be up to date and encompass the complex needs of the service users. Risk assessments have been expanded to encompass the complexities of the service users needs. Social profiles and care plans are now in place for all service users. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 6 Evidence was seen of a more detailed activity programme and of one to one sessions with the more frail service users. The medication administration charts continue to be audited on a weekly basis and significant improvement has been made to the administration practices in the home, which ensures the health needs of the residents are met. Call bells were found in reach of the residents and those residents that do not have the capacity to ring for assistance are checked on a regular basis and this is documented on an hourly basis. However this needs to be extended to the service users in the lounge areas. Staff training has continued to be provided on a number of key topics such as infection control, moving and handling and adult protection, including whistle blowing ensuring that staff have the skills to meet service users needs. There is an on-going maintenance programme ensuring all parts of the home remain homely and comfortable. Water temperatures were found to be consistent, and are regularly checked. The communal bathrooms were found clear of excess equipment and were all in use. The general standard of maintenance and cleaning in the home has improved and feedback from service users relatives and direct observation during the inspection confirm this. The recruitment process is more robust and provided evidence that two written references and current Criminal Record Checks are received prior to commencement of employment. The induction programme is more detailed and regular supervision sessions have been commenced. What they could do better: All service users need to have a full assessment of needs completed with the associated risk assessments on admission, it is not acceptable for any service user to be cared for by staff with no guidance in place as to how to meet her needs. Staffing levels need to be reviewed on a regular basis, a reason given by staff working in the home for a service users’ admission assessment and care plan not being in place was due to the heavy workload and insufficient time. Activities take place every afternoon and the feedback from staff, service users and relatives regarding the small numbers attending is that the majority of service users are very frail and return to bed in the afternoons. The activity programme needs to be based on what suits the service users needs and preferences and not for the convenience of staffing levels. Service users restricted to their bedrooms were noticed spending a large amount of time isolated, with little interaction apart from the in-house mandatory hourly check. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 7 The staff need to be more aware of religious diversity in the home especially in dealing with meals and specific last rites. 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. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 8 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 Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 9 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): 1, 2, 3, 4 and 5. Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service and pre-inspection questionnaire. The pre-admission procedure is followed therefore ensuring the prospective service users needs can be met when admitted to Kestrel House. EVIDENCE: The Statement of Purpose and Service Users Guide (information pack) were viewed, they were found to be in need of updating in respect of the structure of staff, details of the manager and a copy of the complaint procedure. These were evidenced as having been updated by the second day of the inspection. Six pre-admission assessments were viewed and the standard of these documents have been maintained to an adequate standard and were found to be completed in full. Again the home need to be careful in ensuring that the residents being admitted to Kestrel House meet the registration category of the home and the home can meet their expected needs. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 10 The Discharge Co-ordinator from the hospital completes a full nursing assessment to ensure the service users smooth transition from hospital. In the event of a quick discharge from the hospital, it is not always possible for the relatives to be present at the pre-admission assessment, but the staff continue to endeavour to promote their involvement. One relative confirmed that they had been present at the assessment. Two other relatives were aware of the intended transfer to the home, but were not involved in the preadmission assessment. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 11 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 and 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All aspects of service users health, social and care needs have been identified and planned for, which direct staff in the delivery of appropriate care. EVIDENCE: A sample of six care plans were viewed and the improvement seen at the last two inspections has been maintained for five of the ones viewed. One care plan had not been completed despite the service user having high and complex needs and in the home for three weeks. An immediate requirement was made that the care plan and risk assessments for this service user be completed. Reviews of care plans are performed monthly and this includes the update of any risk assessment such as the pressure areas and manual handling assessment, and the update of the base line observations. There is still a need to remind staff to ensure they complete fluid and turning charts as they perform the care. Three fluid and turning charts viewed had not been completed for twelve hours, which give an inaccurate reflection of the care given for the service users. There was evidence of mental health problems of service users affecting other service users heath and safety, this needs to be dealt with more robustly in the care plans and be reflected in the risk Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 12 assessments. Feedback from staff also demonstrated that they need further guidance and support in dealing with behavioural issues. There was evidence in the care plans that the home maintain a close link with the hospital tissue viability nurse and physiotherapists and treatment initiated in hospital is continued when the resident transfers to Kestrel House. There are four residents with tissue damage at the moment and the documentation regarding the treatment and accompanying risk assessments were found to be accurate and up to date. Areas that were found incorrect or poorly completed whilst viewing the care plans were discussed with the senior nurse at the time of the inspection. Systems are in place to ensure service users have access to GP’s, chiropody, dentists and opticians. Three visiting health care professionals were informally interviewed and were happy to share their views on Kestrel House. “I am aware of the changes in the home and over the past year have seen a definite improvement in the documentation and in the communication of the staff. The service users are cared for in a dignified manner and I have no concerns regarding the level of care given”. “ The staff have responded well to training and this is reflected in the care given to the service users in Kestrel House, we have been approached to provide the staff with guidance in passive exercises for those who are unable to move, and we see this as a positive move and will be happy to encourage this”. “The home is definitely cleaner and brighter than it was and the rooms seem more homely”. “Would like the staff to be more visible, and interact more with the less abled, but it has improved considerably”. The health professionals confirmed that they will complete regular surveys over the year for continued feedback. Service users and relatives feedback regarding the care throughout the two day inspection was in the main positive, One service user said that they had given him back his life, and would soon be going home to be near his family. “When I came here from hospital, I could not walk and had to rely on the nurses for everything, five months later I can walk with a stick and visit all the less fortunate people. They have encouraged me so much, I didn’t realise places like this existed”. “The staff try very hard, but they are always rushing and don’t have time to stay and chat” “The care seems ok, my husband likes it here, I visit everyday and the staff always tell me how he is and if anything has changed”. “My friend has only been here a short while, but they seem to have organised everything well”. “My sister is not the usual type of resident, but they are very kind, I would like to see more stimulation and brighter décor, but the Occupational Therapist is putting forward ideas to the home manager and then we can add some mobiles and lights”. “The food is fine, but I do tend to bring in food from home as I know that she doesn’t always eat very well”. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 13 The clinical rooms were found to be clean, tidy and well stocked. Policies and procedures for the administration, receipt, storage and disposal of medicines are accessible to all staff and are updated as required. The medication administration record charts have been maintained to an adequate standard and were seen to be completed correctly. However staff still need to sign and date when medications are changed by verbal order from the G.P. Recommendations were made in respect of ensuring the correct storage of certain medication, to ensure it complies with the manufacturers instructions. The medication audit has continued to be performed by the manager; this has been successful in improving staff documentation. The midday medication round was observed and good practice was observed in the administration and recording of medicines. All service users spoken with said they felt well cared for and all mentioned the kindness and care given by staff. Staff were seen to treat service users with consideration, care and respect. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 14 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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Meals remain good in respect of both quality and variety that meets service users tastes and choice. The lifestyle experience by service users does not always match their expectations, choice or preferences. EVIDENCE: The activity co-ordinator has worked hard since the last inspection to produce individual social profiles on all service users and to develop care plans. There are also records available evidencing one to one sessions with some of the frailer service users. Daily afternoon activities are provided and service users leisure preferences are now recorded in their specific care plans, however there was no evidence to demonstrate how service users are encouraged to participate in activities. Through discussions with service users, relatives and staff it was found that it might be beneficial to vary the times of planned activities as many service users retire to bed in the afternoons to rest and so the number of service users participating is fairly low. Two service users spoke of the sessions and how much they enjoyed them. One service user unable to communicate verbally, demonstrated by sign language how much he enjoyed the films and the musical afternoons, his wife also confirmed that she kept him company and Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 15 thought they were enjoyed by all who attended. Five service users said they did not attend the activities, two said they were not asked and two said they preferred to rest. One declined to answer. It was again a concern that the frail service users who do not leave their rooms spend long periods of time alone. It was noted from available documentation and discussions with staff that they do check the service users hourly, but it is a check only. Ways of encouraging positive interaction were discussed, in the form of passive exercise sessions, and staff who were seen doing NVQ work in the dining areas, could be sitting in service users rooms instead. This is an area that is going to be explored by the manager and activity co-ordinator. One service user told the inspectors she likes gardening but this was not recorded in her care plan and the staff appeared unaware of this preference. Visitors were seen within the home and service users told the inspectors that their families and friends visit and are made welcome by staff. One service user told the inspector he is happy to remain in his room with his television and newspapers but does enjoy a chat when staff have time. Service users rooms have been redecorated, but some were sterile in that there were plain with no pictures or personal effects. Ideas of how to provide warmth and stimulation to rooms were discussed. The bathrooms have been redecorated with murals, which staff say the service users enjoy. Service users religious preferences were recorded in care plans, two were of a different religion, but no information was found as to how they have access to an appropriate service if they so wish. A hairdresser regularly visits the home to provide this service to both male and female service users. The midday meal on both days was observed. It was attractively presented and all service users spoken with commented on the quality and choice of meals. Discussion with the cook and kitchen staff found that they are knowledgeable about special diets and take time to prepare tasty meals that meet special dietary needs. It was noted that the chef was not aware of two service users religion, which would affect some of the meals offered. Menus for all meals are varied and choice is offered for all meals. Two relatives and four service users spoken with confirmed that they thought the meals were of a good standard, with a varied choice. However the relatives also mentioned that fresh fruit was not always offered and that the evening choice was not substantial enough, one example given was a choice of soup and sandwiches, or sardines on toast. It was discussed of ways to seek the service users views by conducting weekly surveys, targeting the evening selection, and then reviewing the results to ensure that the service users are having a choice as to what they prefer. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 16 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, 17 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a satisfactory complaints system with evidence that service users felt confident their views would be listened to. Staff have been trained in the protection of vulnerable adults, improvements need to be made to ensure they remain familiar with whistle blowing procedures so that service users are not at risk of harm or abuse. EVIDENCE: A policy and procedure is in place for dealing with complaints and this is also outlined in the statement of purpose and on the wall in the reception area. The service users guide (welcome pack) in service users rooms did not have a complaints procedure in, but the home administrator rectified this by the following morning. The manager is aware of the timescales set down for dealing with complaints and a complaints register is available. The staff need to ensure that any verbal complaint received is logged immediately and responded to within the time restrictions set. One relative said that she had repeatedly raised concerns about various things, but never received any action, without written evidence it becomes very difficult to resolve on-going issues. One complaint has been received by the CSCI via the Primary Care Team (PCT), regarding food and medication issues and it has been returned to the home manager, who is conducting an investigation into the concerns at present. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 17 The Adult Protection policy in the home was found to be up to date and staff interviewed were confident in their knowledgeable about the systems in place to protect vulnerable residents. The importance of whistle blowing is to be reinforced to all staff to ensure the protection of service users. There is on-going training for all staff in Adult Protection, and this is evidenced in the staff training records. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 18 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, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of decor within the home continues to improve as part of an ongoing programme with all areas homely and comfortable for service users. EVIDENCE: A tour of the premises was carried out and most parts of the home are adequately maintained and décor is in good repair. The home was purpose built and designed with input from the Health Authority. There is level access to all parts of the home, the size of the corridors and rooms are spacious to allow safe movement of chairs and wheel chairs. Each floor has a dining room and two separate lounges, the dining rooms have recently been upgraded and redecorated and are homely and pleasant. The lounges and serveries are awaiting redecoration and refurbishment. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 19 There are communal bathrooms with the necessary specialised equipment to bathe residents. One bathroom has recently been redecorated and has murals on the walls, which the service users enjoy. The service users’ bedrooms are furnished to meet their individual needs and preferences. Some service users and their families have individualised their room with pieces of furniture and personal paintings. Some rooms were seen to be lacking warmth and personality. Bedroom doors are not routinely provided with locks but residents are being offered the choice of one and risk assessments are in place regarding this. A lockable drawer with a key is routinely provided. The three rooms used as shared accommodation all have privacy curtains. Garden areas are attractive, well maintained and assessable to wheelchairs. The activities room is creatively designed and well stocked, but is kept locked when not in use, which may prevent staff at weekends from offering books, tapes and art equipment. The maintenance of the property has been maintained to an acceptable standard, two small problems were identified at the time of the inspection and dealt with immediately. Water temperatures were randomly checked and were found to be of the required temperature, regular testing is documented on a regular basis. The home have the specialised equipment available to meet the needs of the service users. The call bells were found to be accessible for the residents, and those that do not have the mental or physical ability to ring the call bell are checked regularly and the necessary form completed. The response to call bells during the inspection were prompt. However the service users in the lounge areas did not have access to a call bell, staff need to ensure that the call bell are assessable or a member of staff in the lounge area supervising. The overall cleanliness of the home was seen to be of an improved standard. There was an unpleasant odour on the ground floor, which staff were aware of and are trying to rectify. Two carpets were seen to be badly stained and brought to the manager’s attention as a matter of urgency. Equipment for the communal use of service users was found badly stained and in need of cleaning, hoist slings were seen used without the appropriate cover, leading to a risk of cross infection. Good practice was observed in the use of gloves and aprons. The home has all relevant policies and procedures in place concerning infection control and these need to be reinforced to all staff to ensure good practice. Laundry facilities are available in-house and provide a good service. There was positive feedback from service users about the standard of the laundry service. Service users and their families spoken with expressed no concerns over the level of cleanliness. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff training has improved, but service users would be better protected by a review of staffing levels based on service users dependency levels. EVIDENCE: Staff rotas were viewed and staffing on duty for the ground floor is two trained nurses and four carers morning shift, two trained and three carers afternoon shift. On the first floor there are two trained and five carers on duty each morning and two trained and four carers during the afternoon and evening shifts. Two trained nurses and three carers, all waking staff cover the night shift. Staffing levels need to remain under review as staff spoken with said that the morning shifts are rushed due to the high needs of some service users, sometimes resulting in missed baths and rushed caring of the service users. The increased dependency levels of some service users, especially those who have become confused, were noted during discussion with service users, the staff and from information in care plans. There is evidence of an induction-training programme and this is completed over 6-12 weeks. Foundation training has been confirmed by the manager and staff as having been commenced through a recognised agency. Three members of care staff referred to their training booklet, which they are in the process of completing. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 21 Staff continue to be offered the opportunity to attend study sessions that are related to the care of the residents cared for in the home, and staff interviewed spoke enthusiastically of the training opportunities given to them. Two members of staff said they would benefit from training in caring for people suffering from dementia, and managing aggression, this was relayed to the manager. Staff training since the last inspection has been provided for staff in respect of fire safety, first aid, infection control and manual handling, all of which enable staff to effectively and safely deliver care. National Vocational Qualification training is on going and 75 of care staff are enrolled on the NVQ training programme. The home has policies and procedures on recruitment and the personnel records viewed found that the procedures are followed. Recruitment records showed that all recently employed staff had provided a Protection Of Vulnerable Adults/Criminal Records Bureau check prior to appointment and that they provided all the proof of identity required under Schedule 2 of the care homes regulations 2001. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 22 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, 34, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of this home is good with effective systems in place to protect service users. EVIDENCE: Ms Potter has been in post as registered manager for seven months. She has worked at Kestrel House for five years, gradually taking on more responsibility and senior posts. She has worked closely with the previous manager for approximately eighteen months as deputy manager. Ms Potter has commenced her management qualification and is due to complete in the latter part of 2006. There is evidence in the personal records of staff that formal supervision sessions have commenced, but some staff are unsure if they have had these sessions. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 23 The formal quality assurance and quality monitoring systems in place enable the provider to critically evaluate the service and ensure it is run in the service users’ best interests. Service users are responsible for their own finances if appropriate; relatives and solicitors support others, while the home does not handle the financial affairs of service users. Documents used for recording items held by the home were viewed and found to be satisfactory with receipts provided for all items handed over for safekeeping. The accident book was viewed and were found competently completed. Records were available to demonstrate that fire alarms, water temperatures and emergency lighting systems are regularly tested and fire drills undertaken. Testing of portable electrical appliances has been carried out. Certificates to demonstrate that bath hoists, gas appliances, electrical systems and appliances are safe were provided. Since the last inspection all staff have received the mandatory training in moving and handling and fire safety therefore safety for staff and service users is maintained. A risk assessment of the grounds and premises in respect of all safe working practices has been undertaken to enable the manager to identify areas of risk. The premises are protected by a key lock entry system, and a visitor book is displayed at all times. The reception area is manned from 0830 hours to 1700 hours. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 2 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 2 3 2 Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 25 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 Standard OP7 Regulation 15 (1) Requirement All service users must have a detailed plan of care based on the pre-admission assessment and including information on how care is to be delivered. That service users psychological health and social needs are monitored regularly and preventative and restorative care provided. That appropriate risk assessments are in place. (Previous timescales of 17/01/05 & 10/07/05 not met). That records concerning service users nutritional intake and needs are kept accurate and up to date. (Previous timescale of 10/07/05 not met.) That planned activities are flexible to reflect the service users needs and preferences. That staff demonstrate awareness of religious diversity in the home. Timescale for action 18/04/06 1. OP8 13(1b) 17(1a) Sch 3 18/06/06 2. OP8 13(1b) 17(1a) Sch 3 16 (2) 16 (3) 18/04/06 3. 4. OP12 OP12 18/06/06 18/06/06 Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 26 5. OP26 23(1)(a) (d) 6. 7. 8. 9. OP22 OP38 OP27 OP36 13(4) 23 (2n) 13(4) 23 (2n) 18 (1) (a) 18 (1) (2) That all equipment in use for service users is kept clean and hygienic. That appropriate hygienic covers are used for slings and hoists. That the carpets identified are deep cleaned or replaced. That all lounge areas have accessible call bells or a member of staff supervising. That all lounge areas have accessible call bells or a member of staff supervising. That staffing levels are flexible and reflect the complex needs of the service users. That all staff receive formal supervision at least six times a year as under Regulation 19 (1) (a-c). 18/04/06 18/04/06 18/04/06 18/06/06 18/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP9 OP15 OP16 OP18 Good Practice Recommendations That medications are stored as directed by the manufacturer. That the chef conducts a survey regarding meals and choices to ensure all service users have a choice in the development of menus. That all verbal complaints are documented and acted on as per the complaints procedure. That all staff receive a refresher in the whistle blowing procedure. Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Kestrel House DS0000014006.V289280.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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