Inspection on 05/10/05 for Kexborough House

This inspection was carried out on 5th October 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 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

Kexborough House 22/03/07

Kexborough House 15/03/06

Kexborough House 01/10/04

Kexborough House 01/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

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 Kexborough House 113 Churchfield Lane Kexborough Barnsley South Yorkshire S75 5DN Lead Inspector Mr Steven Vessey Unannounced Inspection 5th October 2005 11:05 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.V254912.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. Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 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.V254912.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st October 2004 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 en-suite 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 service users 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.V254912.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately four hours from 11:05 to 15:15. The inspection process included a partial inspection of the premises, inspection of a sample of records and policies, discussions with staff, residents and relatives and observation of staff carrying out their duties. The majority of residents and staff were seen during the inspection and the inspector had the opportunity to speak to six staff, four residents and relatives in some detail. What the service does well: What has improved since the last inspection? The dining room and the corridors had been decorated recently and there is an ongoing plan for the redecoration of residents’ bedrooms. Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 Page 6 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.V254912.R01.S.doc Version 5.0 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.V254912.R01.S.doc Version 5.0 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): 3, standard 6 was not applicable at the home. Residents had a detailed assessment of their needs prior to admission to the home. EVIDENCE: Three care plans included a full needs assessment completed by someone from the home. Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 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): 7, 8 and 9. Residents had signed a detailed up to date plan of care reflecting their identified assessed needs. In the main the health care needs of residents were met, however this would be improved if a risk assessment relating to falls was included in residents care plans. Medication was managed safely and securely stored. EVIDENCE: Three care plans included detailed information as to the actions required by staff to meet the needs of residents. Care plans were reviewed and updated regularly. Some care plans included risk assessments, however care plans for residents who had fallen did not include a risk assessment relating to falls. Residents or relatives had signed care plans. Residents seen were well cared for, they were clean, their hair and nails had been attended to and male residents had been shaved. Residents stated that the chiropodist visited the home regularly and that the manager supported them to attend GP and hospital appointments, meeting the health care needs of residents. Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 Page 10 There were records of medication coming into and leaving the home. There were medication administration records for residents, which were completed appropriately, maintaining resident’s health safety and welfare. Appropriately trained staff administered medication and medication was stored safely, maintaining the health safety and welfare of residents. In the main the pharmacist dispenses medication in monitored dose cassettes on a weekly basis. However one medication was dispensed in a bottle and the 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. Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 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): 12, 13 and 15. Residents are given choice in many aspects of their lives, allowing them to maintain their independence and were happy with the activities and outings on offer. Relatives and friends are encouraged to visit and participate in some aspects of resident care enhancing the quality of life of residents. There is a high level of involvement with the local community. Residents receive a choice of food, which is of good quality and can eat in a pleasant dining room or their room. EVIDENCE: Residents and staff stated that residents could make choices about many aspects of their daily lives, maintaining choice and independence. Some activities were offered to residents and care staff were observed spending time with residents. Staff stated that special occasions were celebrated at the home and that residents were encouraged to go out into the local community. Relatives stated that the manager was involved in taking residents out into the local community. Relatives were seen visiting throughout the day and stated that they could visit any time and were welcomed into the home. Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 Page 12 Residents stated that their friends and ministers from the local church visit regularly and staff stated that communion is provided regularly for residents. Residents were happy with the quality, quantity and choice of food offered, comments included “lunch was nice”, and “the food is quite good”. Residents stated that specific dietary preferences were well catered for. Residents could choose to eat in the dining room or in their own room. The dining room was pleasant and well prepared prior to lunch being served. Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 Page 13 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 and 18. The complaints procedure was available, people were aware how to complain and thought that their complaints would be listened to and dealt with. Procedures were in place to protect residents from abuse, adult protection training would increase the level of protection for residents. EVIDENCE: The complaints procedure was on display. Residents stated that they would speak to the manager if they were unhappy; they felt that the manager would listen to them and that he would try and sort out any problems. Relatives stated that they had received information about how to complain and confirmed that the manager would listen and act on any complaints. The complaints log contained the required information; no complaints had been recorded recently. Residents and relatives stated that they felt the home was safe. Staff were aware of the policies and procedures relating to abuse, including whistle blowing but staff spoken to stated that they had not received adult protection training. Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 Page 14 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, 24 and 26. The home was in the main maintained and decorated to a high standard. The indoor and outdoor communal facilities were comfortable residents enjoyed the pleasant gardens. Residents were happy and comfortable in their rooms. The home was clean and free form any an unpleasant odours. EVIDENCE: In the main the environment was well maintained. The dining room and the corridors had been decorated recently and there is an ongoing plan for the redecoration of residents’ bedrooms. The door to the disabled toilet in the foyer was damaged and detracted from the otherwise high standard of décor around the home. This was discussed with the manager, following the inspection who stated that he would ensure that this was repaired. Some residents were sat in communal areas; some stated that they preferred to spend time in the TV lounge whilst others preferred the quiet lounge. Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 Page 15 Residents were able top use a small room next to the foyer to spend time with relatives or other visitors. Resident stated that they liked to spend time sitting in the garden when the weather allowed this and commented on the very pleasant surroundings. In the main residents were happy with their rooms stating that they were comfortable and had everything that they need. Residents and relatives stated that the home, including their bedrooms was always kept clean and that there were no unpleasant odours around the home. Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 Page 16 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 and 30. Sufficient staff with an appropriate mix of skills was on duty to meet the needs of residents. More than 50 of care staff are NVQ trained. Induction training is provided and staff receive further training to assist them in meeting the needs of the residents. EVIDENCE: On the morning of the inspection a team leader and two care staff, a domestic and a cook were on duty. Staff and some residents stated that there was enough staff on duty to care for residents. Most of the staff spoken to stated that they had competed NVQ level 2 in care and some had moved on to do NVQ level 3 in care. Staff stated that they had received induction training and had other opportunities for training. Residents stated that they were satisfied with the level of care they receive and that staff knew how to care for them, comments included, “Staff are nice and “we are well looked after” Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 Page 17 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 and 38. The manager was experienced and competent to run the home. Residents and relatives were asked their views about the home. The health safety and welfare of residents and staff were in the main protected, however this could be improved if some staff had up to date first aid training. EVIDENCE: The manager was experienced and competent to manage the home, relatives stated that the manager was very caring and ensured that residents are cared for to the highest standard. Comments included, “The manager looks after the residents better than some people look after their parents”. Some staff stated that they were consulted about the running of the home and stated relatives are involved in decisions relating to the care of residents. Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 Page 18 Staff spoken to stated that they had received fire and moving and handling training. Staff in charge of the building confirmed that they had taken part in a fire drill and that fire drills took place regularly at various times during the day, promoting the health safety and welfare of residents and staff. Some staff stated that they had received first aid training but thought that this was in need of updating. Accident records were in place, completed appropriately and reference to accidents was recorded in individual residents care plans. Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 Page 19 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 3 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 4 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X X X X 2 Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 Standard OP8 OP18 OP38 Regulation 15 13 23 Requirement Residents care plans must include risk assessments relating to falls. All staff must receive adult protection training. An assessment of the current level of first aid training must be carried out and training provided where required. Timescale for action 05/01/06 05/01/06 05/01/06 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 Refer to Standard OP9 Good Practice Recommendations A risk assessment should be completed and a written procedure developed in discussion with the pharmacist for the process where the manager inserts specific medication into monitored dose cassettes. Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 Page 21 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 © 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 Kexborough House DS0000018260.V254912.R01.S.doc Version 5.0 Page 22 - 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. 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