Inspection on 09/02/06 for Key West

This inspection was carried out on 9th February 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

Key West 05/03/07

Key West 13/10/05

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 9th February 2006 1:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Key West DS0000020024.V285574.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. Key West DS0000020024.V285574.R01.S.doc Version 5.1 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.V285574.R01.S.doc Version 5.1 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. 13th October 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.V285574.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 3.75 hours and was a routine unannounced inspection. The last inspection took place in October 2005 and was an unannounced inspection. Two residents, one member of staff and the Manager were spoken to, records were inspected and there was a brief tour of the premises. Case tracking of residents was not carried out: this methodology was used at the last inspection. The focus of this inspection was on progress made on the requirements and recommendations made, and those standards not assessed, at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: The Manager must attend a Derbyshire Adult Protection training course and achieve a qualification, at level 4 NVQ, in management and care or equivalent. Staffing hours must be maintained at required levels at all times and an accurate copy of the staff duty rota must be kept. Key West DS0000020024.V285574.R01.S.doc Version 5.1 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.V285574.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 Key West DS0000020024.V285574.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): This section was not assessed at this inspection. EVIDENCE: Key West DS0000020024.V285574.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): 7, 8, & 9 Residents’ health, personal and social care needs were set out in individual plans of care and staff were planning their care programmes on these. Residents’ health care needs were being met and they were being protected by the Home’s procedures for dealing with medicines. EVIDENCE: The care plan of a resident admitted in January 2006 was examined and found to be a holistic and constructive document. The care plan review sheet was comprehensive and covered all aspects of the care plan. The Manager stated that, as part of the review process, key workers work through the care plan with each resident every month and record any changes. The Manager was the designated person to monitor issues of continence management and skin viability within the Home. She and the Deputy Manager had undertaken training on continence management in 2005. Risk assessments included the risk of residents falling. Health professionals were involved on a regular basis with residents and there was a system to record this contact. District nurses had supplied specialist mattresses for residents prone to pressure sores and the Home had its own supply of pressure Key West DS0000020024.V285574.R01.S.doc Version 5.1 Page 10 cushions. The Home was now being serviced by an area district nurse with whom the Home had a good working relationship, the Manager stated. Tissue viability assessment charts were being maintained as well as residents’ weight records. A sample of the Home’s medication records were examined and found to be satisfactory. Handwritten entries were being signed, dated and countersigned. There had been a change of pharmacy since the last inspection and this had had positive implications for the recording system and other aspects of the medication system. One resident stated that staff were respectful and had a good sense of humour. A member of staff spoke about residents being provided with private space when visitors came and personal care being provided with due attention paid to matters of privacy and dignity. Other aspects of standard 10 were not assessed on this occasion. Key West DS0000020024.V285574.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): 13, 14 & 15 Residents were able to maintain contact with family and friends and the local community. They were helped to exercise choice and control over their lives. They were provided with a varied and appealing diet. EVIDENCE: One resident spoke of having enough to occupy him each day and he was very positive about life at the Home. Routines were flexible, he added. One member of staff spoke of a good range of entertainment being available for residents and this confirmed the assessment made at previous inspections. Other aspects of standard 12 were not assessed on this occasion. All nine of the residents had some contact from visitors, the Manager stated. Some of these visitors continued to visit the Home after the resident had left. There were no restrictions on visiting times – visitors were “welcome at any time”, the Manager said. Local individuals provided therapy and entertainment for the residents, she added. Some residents were managing small amounts of money for items such as hairdressing. Bedrooms reflected the Home’s policy of enabling residents to bring personal possessions with them – bedrooms were well personalised. One staff member spoke of the importance of residents maintaining their Key West DS0000020024.V285574.R01.S.doc Version 5.1 Page 12 independence as long as possible – achieved, in part, by staff not carrying out tasks that residents could undertake for themselves. One resident spoke of breakfast time being flexible and of this being of “excellent” quality – particularly in view of his preference for a cooked breakfast being met every day. He said that all other meals were very good, too – adding, that he had a good diet and food was well presented. Key West DS0000020024.V285574.R01.S.doc Version 5.1 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): 18 Residents were being protected from abuse. EVIDENCE: The Manager stated that her Deputy and one care assistant had attended a Derbyshire County Council adult protection training course in August 2005. She, herself, was unable to attend this course and intends to apply for another one. The member of staff spoken to was confident that she and the other staff would tell a colleague if they saw inappropriate behaviour displayed and, if of a serious nature, they would immediately inform the Manager. She confirmed she was aware of the Home’s whistle blowing policy. Key West DS0000020024.V285574.R01.S.doc Version 5.1 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): This section was not fully assessed. EVIDENCE: All areas of the premises that were inspected on this occasion were found to be extremely clean and tidy and nicely decorated and furnished. A new set of pictures had been hung on ground floor corridor walls and there was a new fish tank in the lounge. Other aspects of this section were not assessed on this occasion. Key West DS0000020024.V285574.R01.S.doc Version 5.1 Page 15 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, 29 & 30 Residents’ needs may not have been fully met by adequate numbers of staff. They were being protected by the Home’s recruitment policy although this needed to be updated. Residents were benefiting from a well-trained staff group. EVIDENCE: The staffing rota for week commencing 29 January was examined. It was found to be 58.5 hours below the minimum weekly hours required for a home of this size – as set out in standards in force at the 31st March 2002. The Manager pointed out that not all her hours worked that week had been recorded on the rota. The member of staff spoken to talked of residents benefiting from a consistent staff group. The file of a care assistant appointed in April 2005 was examined. All matters relating to her recruitment were satisfactory. However, the Manager was unaware of changes to the Regulations in July 2004 and the Inspector offered to send her a copy of these changes. The member of staff spoken to said she had received full induction training and was able to confirm she had been provided with all mandatory training too. Key West DS0000020024.V285574.R01.S.doc Version 5.1 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): 31, 32, 34 & 35 Residents were living in a home run and managed by a person who was fit to be in charge and able to discharge her responsibilities fully – although she had not achieved the required level of qualification. Residents were benefiting from the management approach of the Home and safeguarded by the accounting and financial procedures of the Home. EVIDENCE: The Manager said that her Deputy had nearly completed the Registered Managers Award although she herself was further from completion. The Manager is very experienced having been owner/manager of Key West for 18 years. Her competence can be measured by the high service standards maintained. The Manager has undertaken the same training courses her staff have attended and she showed she was familiar with the conditions associated with the aging process. Since the creation of a deputy post two years ago the Manager explained that she has been able to take a more ‘hands-on’ role and ensure high staffing standards through direct observation. It was noted that Key West DS0000020024.V285574.R01.S.doc Version 5.1 Page 17 the job description for the post of senior care assistant made reference to the responsibilities of ‘person-in-charge’, as previously recommended. The staff member spoken to said that there were “excellent standards of care” in the Home. She added that “we all get on very well as a staff group” and that the Home was “a pleasant place to work”. By the front door was a ‘Meet the Staff’ board showing photos of staff. The Home’s business plan, dated August 2005, was well worded - giving valuable insights into the business. The Manager stated that the Home held no money on behalf of residents. There was a safe, and receipt book system, should they request that valuables were kept for them. Key West DS0000020024.V285574.R01.S.doc Version 5.1 Page 18 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 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 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X 3 3 X X X Key West DS0000020024.V285574.R01.S.doc Version 5.1 Page 19 Yes Are there any outstanding requirements from the last inspection? 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 OP18 Regulation 13(6) Requirement The Manager must attend a Derbyshire Adult Protection training course. (Previous timescale was 01/02/06) The registered person must ensure that staffing hours are maintained at required levels at all times. (Previous timescale was 01/12/05) The registered person must maintain an accurate copy of the staff duty rota. The registered manager must achieve a qualification, at level 4 NVQ, in management and care or equivalent. Timescale for action 01/06/06 2. OP27 18(1)(a) 01/04/06 3. 4. OP27 OP31 17(2) Sch 4.7 9(2)(b)(i) 01/04/06 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. There were no recommendations from this inspection. Key West DS0000020024.V285574.R01.S.doc Version 5.1 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.V285574.R01.S.doc Version 5.1 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. 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