Inspection on 13/10/05 for Key West

This inspection was carried out on 13th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Key West 05/03/07

Key West 09/02/06

Key West 18/03/05

Key West 20/08/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Key West 203 Tamworth Road Long Eaton Nottinghamshire NG10 1DH Lead Inspector Anthony Barker Unannounced Inspection 13th October 2005 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 Key West DS0000020024.V253460.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. Key West DS0000020024.V253460.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Key West Address 203 Tamworth Road Long Eaton Nottinghamshire NG10 1DH 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) (0115) 9732031 Mrs Hilary Ann Majtas Mr Leszek Jan Majtas Mrs Hilary Ann Majtas Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Key West DS0000020024.V253460.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 1 Day Care Place 1 PD Place. On a named person basis for the person named in the notice of proposal letter. 18th March 2005 Date of last inspection Brief Description of the Service: Key West is a detached building situated on the Tamworth Road out of Long Eaton. It provides care for 9 older people within seven single rooms and one double room. One of the single rooms has en-suite facilities. All parts of the building are accessible to residents. It is a family run Home with one of the proprietors being the Home’s manager. Care is provided by a group of part time and full time staff, plus the Manager. Key West DS0000020024.V253460.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 4.25 hours and was a routine unannounced inspection. The last inspection took place in March 2005 and was an unannounced inspection. Four residents, two staff, one relative and a visiting chiropodist were spoken to, records were inspected and there was a tour of the premises. Two residents’ records were examined as part of the case tracking method. The focus of this inspection was on progress made on the requirements and recommendations made, and those standards not assessed, at the last two inspections. What the service does well: What has improved since the last inspection? What they could do better: There must be improvements to recording practices regarding medicines. Minimum staffing levels must be maintained at all times. All records required by Regulation must be available for inspection at all times. Key West DS0000020024.V253460.R01.S.doc Version 5.0 Page 6 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. Key West DS0000020024.V253460.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 Key West DS0000020024.V253460.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): 1, 3 & 6 Prospective residents had the information they need to make an informed choice about where to live. They had their needs fully assessed before moving into the Home. EVIDENCE: Staff were able to locate a copy of the Home’s Statement of Purpose. It had been improved since the last inspection and now sets out how the Home meets the physical environment standards. All residents are admitted on a month’s trial basis during which time an assessment of needs is undertaken. This needs assessment covers all of the areas identified in this standard. A document is sent to relatives to complete that provides a complete profile of the new resident’s life, family and interests. Intermediate care, as defined in Standard 6, was not being provided by this Home. Key West DS0000020024.V253460.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, 9, 10, & 11 Residents’ health, personal and social care needs were set out in individual plans of care and staff were planning their care programmes on these. However, residents were not being protected by the Home’s procedures for dealing with medicines. Residents were being treated with respect and felt they had a good quality of life. Their wishes concerning arrangements after death were being sought and respected. EVIDENCE: A member of staff said that the new care planning system was working well. She said she felt she knows residents better particularly because of the time she spends with one of the residents as her key worker. She added that she feels more involved in the Home. The care plan sheet and care plan review sheet both have a space for residents to sign to confirm their agreement with the contents and signatures were seen on the two files case-tracked. Relatives will sign when residents are unable. Monthly reviews are undertaken by key workers together with each individual resident. The care plan sheets were holistic in content but not the care plan review sheet. Risk assessments were helpful and regularly reviewed. Residents’ likes and dislikes were recorded. Key West DS0000020024.V253460.R01.S.doc Version 5.0 Page 10 A chiropodist was visiting at the time of this inspection. She visits the Home every six weeks and was very positive about the quality of care provided to the residents. Other aspects of Standard 8 were not assessed. Staff confirmed that a record was being made of medicines received into the Home. Residents’ medication administration record (MAR) sheets were kept in a folder that included residents’ photographs and sample signatures. Also, there was a page for a staff countersignature recorded after each administration session – this was up to date. There was still evidence of handwritten entries on MAR sheets with no countersignature and one with no signature. By working back from the current date it was noted that MAR sheet entries started on 21 September 2005. The pharmacy had printed a start date of 5 September and there were no recorded dates above the weekly columns. This was confusing and mistakes could be made as to the actual day the medication is administered. Staff have been provided with training in the safe use of medicines by an accredited body and they said that certificates have been received. Staff were observed taking a personal interest with residents and treating them with care and dignity. Residents gave a very positive account of life at the Home with one resident saying, “It’s as near perfect as you can get” and two residents agreeing that, “Staff are really good”. One member of staff was heard to involve residents in a spontaneous and brief sing-song. Frequent laughter was heard in the lounge – there was a good atmosphere during this inspection. A cordless telephone was available to residents who wish to make calls in private. A good standard in the appearance of residents was observed. Files indicated that residents are asked about their preferred term of address at the time of admission. Files showed that arrangements after death are considered and there were entries to confirm that this had been directly discussed with individual residents. Residents Personal Profiles included a question on arrangements after death and preferred undertaker. Key West DS0000020024.V253460.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 & 15 Residents’ lifestyles were based on their wishes and preferences and their personal interests were satisfied as far as possible. They received an appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: The Home’s routines were flexible and reflected individual needs and preferences. This was confirmed in discussion with residents. It was also made clear that residents’ need for social, recreational and physical stimulation was being met. A very good range of activities were provided both within the Home and within the local community. There was a displayed programme of October’s activities in the entrance hall – including visiting entertainers and inhouse activities. Food stocks were at a very good level. Meals looked appetising and this was confirmed by residents spoken to. One relative, and all residents spoken to, said that meals were of a good standard. It was clear that personal choices were catered for. The daily menu was displayed in the hall. The Home kept a record of food provided to individually named residents. Key West DS0000020024.V253460.R01.S.doc Version 5.0 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): 16 & 18 Residents were confident that their complaints would be listened to, taken seriously and acted upon. The Home’s systems were protecting residents from abuse. EVIDENCE: The Home’s written complaints procedure was displayed in the entrance hall and was well worded. It explicitly stated that a complainant could approach the Commission for Social care Inspection directly rather than the Home’s Manager if they so chose, and also made reference to the Health Ombudsman. Staff confirmed that they were aware of the complaints procedure. There had been no complaints received within the past 12 months. One resident said that any “niggles” he has are always “sorted”. The Home had a written procedure on Adult Protection and the Prevention of Abuse, that included Whistle Blowing. A member of staff confirmed that she understood the procedure. Key West DS0000020024.V253460.R01.S.doc Version 5.0 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): 19 & 26 Residents were living in an attractive and well-maintained environment that was safe and comfortable. EVIDENCE: The Home was clean, tidy and well maintained. Standards of furnishing and decoration were very high. Three bedrooms had been decorated since the last inspection. Residents and staff expressed their approval following the interchange of dining room and lounge. Following consultation with the Fire Officer locks had been fitted to the fire doors in the two bedrooms, which led onto the fire escape. Other aspects of Standard 24 were not assessed on this inspection. On inspection the Home was clean, pleasant and hygienic. There was a good laundry system in place including a washing machine with a sluicing facility. Key West DS0000020024.V253460.R01.S.doc Version 5.0 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): 27, 28 & 30 A good proportion of qualified and trained staff enabled residents’ needs to be met. However, levels of care may have been compromised by inadequate staffing levels. EVIDENCE: The staffing rota for the week commencing 2 October 2005 showed that the Home had staffing levels below standards. The majority of staff had a combined care, domestic and catering role. Combined hours were 43.5 below the 254 hours required per week. The rota identified the person-in-charge when the Manager was absent and staff members’ surnames were being recorded. A new ‘Meet the Staff’ board was displayed in the entrance hall with photographs of staff. 50 of the staff group had achieved a National Vocational Qualification (NVQ) in Care at level 2, at least, according to the completed pre-inspection questionnaire. Staff recruitment standards could not be assessed as care staff did not have access to staff records in the Manager’s absence. However, the pre-inspection questionnaire showed that all staff had had a Criminal Records Bureau (CRB) check made. This questionnaire gave details of the staff training provided during the previous 12 months. This was very satisfactory. Confirming comments from staff and from staff records were not sought at this inspection. Key West DS0000020024.V253460.R01.S.doc Version 5.0 Page 15 Key West DS0000020024.V253460.R01.S.doc Version 5.0 Page 16 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): 38 The health, safety and welfare of residents and staff was being promoted. EVIDENCE: The Home had an extensive policies and procedures folder, with 87 items. There was an ongoing ‘Policy of the Month’ system and the current policy was displayed in the medication cupboard. Staff confirmed they recorded their signatures when they had read the policy. Other quality assurance matters were not assessed on this occasion. The current Employers Liability Insurance certificate was displayed in the entrance hall. Cleaning materials were being safely stored in a locked cupboard in the laundry room along with Product Information Sheets. The pre-inspection questionnaire showed that equipment was being checked and maintained appropriately. Good food hygiene practices were being followed. Key West DS0000020024.V253460.R01.S.doc Version 5.0 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Key West DS0000020024.V253460.R01.S.doc Version 5.0 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 Standard OP9 Regulation 13(2) 13(4)(c) Requirement Handwritten amendments to Medication Administration Record sheets must be signed, dated and countersigned/dated by a second member of staff. (Previous timescale was 1 December 2004) The registered persons must ensure that the recording of medicines administered is improved and maintained in accordance with the Medicines Act 1968 and other legal requirements. (Previous timescale was 1 January 2004) The registered person must ensure, after consultation with the Home’s pharmacist, that MAR sheets are clearly and unambiguously marked with dates. The Manager and Deputy Manager must attend a Derbyshire Adult Protection training course. (This requirement from 8 August 2004 was not assessed) The registered person must ensure that staffing hours are DS0000020024.V253460.R01.S.doc Timescale for action 01/11/05 2 OP9 13(2) 13(4)(c) 01/12/05 3 OP9 13(2) 13(4)(c) 01/12/05 4 OP18 13(6) 01/02/06 5 OP27 18(1)(a) 01/12/05 Key West Version 5.0 Page 19 6 OP29 17(3)(b) 7 OP29 7(3)(c)(i) maintained at required levels at all times. The registered person must ensure that all records that are required by regulation to be held – including staff details – are at all times available for inspection. One of the Registered Providers must apply for a CRB check, through the Derby office of the CSCI. (This requirement from 8 August 2004 was not assessed) 01/12/05 01/12/05 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 Refer to Standard OP7 OP31 Good Practice Recommendations The care plan review sheets should follow the same holistic headings as the care plan sheets. The registered manager should aim to achieve a qualification, at level 4 NVQ, in management and care or equivalent by 2005. (This recommendation from 15 April 2003 was not assessed) The job description for the post of senior care assistant should make reference to the responsibilities of ‘person-incharge’. (This recommendation from 12 August 2003 was not assessed) The registered person should provide a business and financial plan for the Home, open to inspection and reviewed annually. (This recommendation from 15 April 2003 was not assessed) 3 OP31 4 OP34 Key West DS0000020024.V253460.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Key West DS0000020024.V253460.R01.S.doc Version 5.0 Page 21 - 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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