Inspection on 12/05/05 for Kilburn Gardens, 53

This inspection was carried out on 12th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Kilburn Gardens, 53 14/06/07

Kilburn Gardens, 53 02/08/06

Kilburn Gardens, 53 08/11/05

Kilburn Gardens, 53 14/12/04

Kilburn Gardens, 53 26/07/04

Kilburn Gardens, 53 04/02/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 53 Kilburn Gardens Collingwood Park Station Road North Shields NE29 6HD Lead Inspector Janine Smith Unannounced 12 May 2005 10:30 th 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 53 Kilburn Gardens Address Collingwood Park Station Road North Shields Tyne & Wear NE29 6HD 0191 272 8714 0191 272 8714 N/A New Prospects Association Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Michelle Anne Coleman CRH 3 Category(ies) of LD - Learning Disability (3) registration, with number of places 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 14/12/05 Brief Description of the Service: 53 Kilburn Gardens provides residential care for three adults with a learning disability. Nursing care is not provided. The home is a bungalow on a housing estate in an outlying area of North Shields. The design of the house is in keeping with the other houses on the estate. Public transport is available a short distance away. The nearest local amenities are in North Shields. The home has a variety of aids and adaptations to mee the individual needs of the service users who have physical disabilities. All of the bedrooms are single. There is a large bathroom which has an assisted bath and a shower and w.c. There is also a separate toilet. The house has a reasonably sized garden at the rear and a lawned area to the front. There is a ramp providing wheelchair access to the front door. 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 5 hours. A partial tour of the premises took place and a sample of care records were inspected as well as other records. All three of the residents and the Manager and three staff were spoken to. What the service does well: What has improved since the last inspection? The menus have been reviewed to ensure that they provide a varied and nutritious diet for residents. One to one staff training is being provided to ensure that the staff team have the skills needed to maintain good care records. A new quality assurance system is being introduced which will enable the organisation to monitor the quality of care provided. The dining room has been improved with new carpets and a dining suite chosen by one of the residents. 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 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. 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 5. Appropriate procedures are in place to ensure that prospective service users’ needs are properly assessed prior to moving into the home, which ensures that the home is able to meet their needs. EVIDENCE: The last admission took place twelve months ago. A full assessment was provided by the service user’s Care Manager. Statement of terms and conditions were in place on the two care records inspected. 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9 The contents and presentation of the care plans needs to be improved, to ensure that the complex needs of the residents are readily identified in the records. Residents’ rights to make decisions about their day-to-day lives are respected by the staff team, which ensures that their lives in the home are fulfilling and satisfying. EVIDENCE: A requirement was made at the last inspection to ensure care plans included full details of how service users’ care needs were being met. This requirement has not been fully met, as additional staff training has been necessary. It was agreed with the Manager that this requirement would be fully met by 31st July 2005. During this inspection two care plans were inspected. They contained a great deal of detailed information about the personal, social and complex health care needs of the service users but the files need some tidying and re-organisation to ensure the information is readily accessible. Members of staff on duty were well informed about the individual needs of the residents. 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 10 Risk assessments have been carried out and are aimed at ensuring residents are able to participate in fulfilling activities. Not all of the residents use verbal communication, however staff could describe how they offer choices to them and carefully observe their body language, which helps the staff to know what they like and dislike. The staff team on duty were observed to do this throughout the day. One resident was seen choosing the foods for a barbecue later in the afternoon and residents later went shopping for these. It was confirmed with the Manager that residents participate in meetings in the home and also in the staff selection process. 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 and 17. Links with the community are good and support and enrich residents social lives. EVIDENCE: Two residents are very involved with Skills for People which helps in their personal development. Discussion with staff and examination of records showed that residents use a variety of facilities in the community, such as Rebound, a Snoozelem, trampolines, swimming pool. They enjoy being part of the local community and use pubs, theatres and a disco. They all keep close contact with their families. The atmosphere in the home was very cheerful and one service user was heard laughing throughout the day as she chatted and joked with members of staff. She told the inspector she liked living here much better than where she was before and that she liked having her own room and the ‘quiet’ in the home. She had enjoyed a recent holiday to Blackpool with staff and frequent shopping trips to choose and buy clothes. 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 12 A nutritious menu plan is in place. Observations made and discussion with staff confirmed that residents are offered choices at all meals and if they do not want the meal on the menu, another of their choice is made and a record kept. 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20. The health needs of residents are well met, other than more thorough monitoring of their weight. The systems for the administration of medication need some improvement. EVIDENCE: Inspection of care records and discussion with the Manager and staff showed that residents are provided with the support they need to meet their personal and health care needs except for regular monitoring of their weight. This was still not being done at appropriate intervals because of the lack of a suitable weighing machine in the community. However, the Manager stated that this would be addressed from the following week as arrangements had been made with a local clinic to use their weighing scales. The home has not purchased its own weighing scales, which was a requirement at the last inspection. Given that this has not been done, the Registered Manager must ensure that the alternative arrangements are carried through. Some of the residents have complex health care needs and the staff are required to carry out particular procedures from time to time as directed by community nursing staff. The staff team have received training in these procedures but there is no documentary evidence from the responsible community nursing staff to confirm that each member of staff has been 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 14 assessed as being competent to carry out these tasks. This remains an unmet requirement as the Manager has been unable to progress this matter. She is, however, arranging for staff to receive accredited training in respect of one particular procedure from another source. A random sample of medication records and the system for storage and handling medication was looked at and found to be appropriate, other than:- some medications did not have a pharmacist’s label attached giving the name of the resident and dosage instructions; and - the administration record had been signed in one case indicating a medication had been given when, in fact, it had not. 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The home has a satisfactory complaints system and staff have been trained in adult protection which helps to protect residents from abuse. EVIDENCE: A complaints procedure is in place and in addition work is ongoing with a service user to produce this in pictorial form. The Manager confirmed that all of the staff have received Adult Protection training and further training is being arranged. 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30. The house provides a suitable environment for residents with physical disabilities. The décor is showing considerable signs of wear and redecoration is needed to create a pleasing and pleasant environment to live in. EVIDENCE: Since the last inspection the dining room carpet has been replaced and a new dining suite purchased which was chosen by one of the residents. The lounge carpet, although not in a dangerous condition, looks worn. Wall coverings are damaged and scuffed. The home was clean and protective clothing is available to staff. 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33. Good staffing levels are maintained in the home which means the staff are able to work effectively with residents. EVIDENCE: On the day of inspection there were three care staff on duty in addition to the Manager. Through the night there is one waking night carer and another sleeps on the premises to provide assistance if necessary. The Manager ensures that there are sufficient staff on duty through the day and evenings to support residents with social activities. There have been some changes in the staff team due to promotions and the temporary re-deployment of staff from another care home, however, this does not seem to have had any negative effect on the care of the residents. 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x 3 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 53 Kilburn Gardens Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 20 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 6 Regulation 15 Requirement Ensure care plans include full details of how care needs are being met in a format which provides easy access to the information. (Previous timescale not met). Residents weight must be monitored at appropriate intervals and a record kept. All prescribed medications must have a pharmacy label attached giving the name of the resident and details of the medication. The care staff must follow correct procedures when administering medication, that is, by indicating on the medication administration record when a medication has been given or the reason why it has not. Where care staff are delegated by nursing professionals to carry out tasks in relation to a PEG or to administer rectal diazepam, the training for the named care workers must be fully documented and the record must incorporate an assessment of the care workers competence, together with all subsequent reTimescale for action 31st July 2005 2. 3. 19 20 12(1) 13 22nd May 2005 31st May 2005 31st May 2005 4. 20 13 5. 20 12(1) & 13 30th September 2005 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 21 assessments. 6. 7. 24 24 23(2)(d) 23(2)(d) Replace lounge carpet. (Previous timescale of 31/1/05 not met.) Carry out redecoration where needed. 30th September 2005. 30th September 2005. 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 20 Good Practice Recommendations Attach photographs to medication administration records. 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR 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 53 Kilburn Gardens B53-B03 S357 KilburnGardens V222079 110505 Stage 4.doc Version 1.30 Page 23 - 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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