CARE HOMES FOR OLDER PEOPLE
Kexborough House 113 Churchfield Lane Kexborough Barnsley South Yorkshire S75 5DN Lead Inspector
Jayne White Unannounced Inspection 15th March 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kexborough House DS0000018260.V278718.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. Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Kexborough House Address 113 Churchfield Lane Kexborough Barnsley South Yorkshire S75 5DN 01226 385046 01226 385046 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) MJM (Furnishings) Limited Mr Michael Matthews Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 5th October 2005 Brief Description of the Service: Kexborough House is a large brick built residence with a single storey purpose built extension that stands in its own well kept grounds, in the village of Kexborough. The home is registered for 21 elderly people and can be easily reached from the M1, motorway junction 38 and following the signs for A637 to Barnsley. Within a short walk from the home is full range of amenities including the post office, health centre, shops, pharmacy, community centre, country pubs, churches and local village club. It is well decorated with 21 single ensuite rooms, three lounges, one dining room and a visitors’ room. Accommodation is on two floors served with a passenger lift. The large gardens are landscaped and include a small orchard, tennis court, putting green, water feature, gazebo and rose garden. There are two large patio areas with easy access for residents’ use. Car parking is available at the front and side of the home. Kexborough House is a Christian home, which operates a no smoking policy. Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over three hours from 10:00 am to 1:00 pm. Two inspectors, Jayne White and Christine Rolt, completed the inspection. The inspection process included a partial inspection of the premises, inspection of a sample of records, observe care practices and talk to staff, residents and the owners of the home. The majority of residents and staff were seen during the inspection and the inspector had the opportunity to speak to two staff about their knowledge, skills and experiences of working at the home and ten residents about their views on aspects of living at the home. What the service does well: What has improved since the last inspection?
Risk assessments relating to falls had been included in residents’ care plans to ensure their health care needs were met more thoroughly. All staff had now received adult protection training, thereby increasing their knowledge of how residents’ can be safeguarded from abuse.
Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 6 The practice of secondary dispensing medication had ceased. This further enhanced the safety of medication administration. 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. Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): See below EVIDENCE: Outcomes for this section of the report were checked and met on the last inspection. Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcome for standard 10 was inspected. For standards 8 and 9 previous requirements and recommendations were inspected. Risk assessments relating to falls had been included in residents’ care plans to ensure their health care needs were met more thoroughly. The practice of secondary dispensing medication had ceased. This further enhanced the safety of medication administration. Observation of care practice and discussions with residents’ identified residents’ were treated with respect and their right to privacy upheld. EVIDENCE: Risk assessments relating to falls had been included in residents’ care plans to ensure their health care needs were met more thoroughly. On the previous inspection it was noted that one medication was dispensed in a bottle and the owner/manager inserted this into the cassette. Discussions with the manager and the pharmacist concluded that, in their opinion, due to the nature of the medication and the frequent changes of dose, the procedure in place was the safest way to ensure the resident received the correct dose of medication. It was recommended that a risk assessment should be completed
Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 10 and a written procedure developed in discussion with the pharmacist for the process where the manager inserts specific medication into monitored dose cassettes. Discussions with the owner/manager on this inspection identified this practice had now ceased. Observation of care practice identified staff interacted well with residents’ and furthermore they were observed closing bedroom and toilet/bathroom doors when attending to residents’. The interactions between residents’ and staff at these times were noted to be courteous. Residents were immaculately presented, indicating an excellent level of attentiveness to personal care needs. All residents’ during discussions with them said their privacy was maintained and staff treated them kindly. Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The outcome for standard 14 was inspected. Residents’ spoken with said they were enabled to remain as independent as possible and make choices in their every day life. EVIDENCE: Residents’ spoken with described how they could choose to spend their day and confirmed that they could choose what time to get up and go to bed. Some of the comments made by residents about their lifestyle at the home included “choices of meals are available”, “anyone who wants to go out can do - they arrange it”, “we go out every Friday to Darby and Joan”, “choices on food - a varied menu over about four weeks”, “I go walking locally”, “in the summer I like to be out in the garden planting and watering flowers” and “you can please yourself what you do. I go walking and to church”. Personal items and furniture were brought into the home by residents to personalise their rooms. Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): A previous requirement for standard 18 was inspected. All staff had now received adult protection training, thereby increasing their knowledge of how residents’ can be safeguarded from abuse. EVIDENCE: One of the owners provided a training matrix to demonstrate that staff had received training in adult protection. They also provided the training course paperwork and the question and answer sheet to be completed by staff after reading the paperwork. Certificates were issued in-house. Staff in discussions with them confirmed this. Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): See below EVIDENCE: Outcomes for this section of the report were checked and met on the last inspection. Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 14 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): The outcome for standard 29 was inspected. That residents’ were supported and protected by the home’s recruitment policy and practices could not be demonstrated, as staff files were not kept at the home. EVIDENCE: During discussions with the owners, they described their recruitment process, which appeared to be thorough, however, this could not be demonstrated, as staff files were not held at the home. Discussions with a member of staff confirmed the recruitment process the owners had described. Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 15 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): The outcome for standard 35 was inspected. An outstanding requirement for standard 38 was inspected. Residents’ were enabled to retain control over their monies unless they didn’t want to or lacked capacity. As the full financial records for one resident were not kept at the home, it could not be demonstrated that all residents were fully protected by the home’s policy for dealing with residents’ monies. The owners/manager were still in the process of identifying an appropriate course for first aid training for staff that would improve the health, safety and welfare of residents and staff. EVIDENCE: Residents’ were able to maintain control over their finances if they wished and had the capacity to do so. Only the owners dealt with the finances of residents to ensure residents’ monies were safeguarded. If residents wanted money when the owners were not on site, a small cash float was available for the staff
Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 16 to access. Written records of all financial transactions were maintained. The record of monies held on behalf of a resident was maintained with the balance and monies correlating. Records described what the monies were used for and one of the owners confirmed this could be correlated by receipts and/or other records. One of the owners was an appointee for one resident. A full financial audit trail of that resident’s monies could not be demonstrated because financial statements were not held at the home. Discussion with the owners identified they were still in the process of identifying an appropriate course for first aid training for staff that would improve the health, safety and welfare of residents and staff. Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 17 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 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 X X 2 Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 18 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 OP29 OP35 Regulation 19 12 & 17 Requirement Staff files must be available for inspection. Where the owner acts as appointee for a resident, bank statements of the resident must be available for inspection. An assessment of the current level of first aid training must be carried out and training provided where required. Previous timescale of 05/01/06 not met. Timescale for action 30/04/06 30/04/06 3 OP38 23 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kexborough House DS0000018260.V278718.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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