CARE HOME ADULTS 18-65
Kilburn Gardens, 53 53 Kilburn Gardens Collingwood Park, Station Road North Shields Tyne & Wear NE29 6HD Lead Inspector
Hilary Stewart Key Unannounced Inspection 2nd August, 2006 10:20 Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 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 Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 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 Adults 18-65. 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. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Kilburn Gardens, 53 Address 53 Kilburn Gardens Collingwood Park, Station Road North Shields Tyne & Wear NE29 6HD 0191 2728714 0191 272 8714 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) New Prospects Association Limited Mrs Michelle Anne Coleman Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users are also categorised as having physical disabilities. Date of last inspection 8th November 2005 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 assist people with physical disabilities. All of the bedrooms are single. There is a large bathroom, which has an assisted bath, a shower and toilet. There is also a separate toilet. The house has a reasonably sized garden at the rear and a small garden to the front. There is a ramp providing wheelchair access to the front door. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 10:20hrs. It took place over 5 hours. All of the residents were at home at the time of the inspection. The inspector spoke to the residents, two members of staff and the deputy manager. Records and the building were examined. Four questionnaires were returned. What the service does well:
The staff team at the home value the differing needs of the residents who live there and make sure that they are aware of each person’s preferences. They treat the residents as individuals and support them to live the life they choose as much as possible so they will gain confidence. Staff make a lot of effort to enable the residents to experience a variety of activities so they have more choice. This helps build their self-esteem and confidence. The staff team make sure that the home is clean, warm and pleasantly furnished so the residents can be comfortable and relaxed. Staff work hard to enable residents to use local services so they are part of the community. There are procedures in place at the home that make sure that the residents are protected and kept safe from abuse. The staff are supervised and trained so they know how to provide the residents with good care. Staff listen and talk to the residents to support them to make informed decisions about their lives so they feel their opinions are valued. The staff make sure the residents health care needs are met so their good health is maintained. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
When residents are admitted to the home, if the homes procedure are followed, residents will have more time to become more familiar with the service. The home has a quality assurance system but it needs to be implemented to ensure the home can continually improve its service to the residents. Residents care plans have been updated some areas still need more work to ensure that they are an up to date accurate record of how their care needs are being met in the home. More storage is needed in the home so there is more space available for the residents. Regular fire instruction for staff will make sure they know how to keep the residents safe if there is a fire at the home. Staff training in how to protect vulnerable adults will give the staff more skills in how to keep the residents that they care for safe. Repairs to the doors and benches in the kitchen would improve the look of the home and make it more pleasant for the residents. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 7 If copies of the reports from the monthly monitoring visits were sent to the home the manager would be able to use the findings to improve the service to the residents. Monthly monitoring of the residents weight would make sure the staff were aware of any dramatic changes and the health implications for the residents. If all of the residents have their benefits paid directly to them, the home can invoice them for their care fees. This would make sure that the residents are in control, as much as possible of their own finances. 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. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 2 and 4 Quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. The residents have their needs assessed at the home so individual care plans can be developed. This makes sure that the residents are getting the care that they need. The homes admissions procedure is not always followed this has caused disruption and anxiety to the residents. EVIDENCE: The staff involve the residents as much as possible in developing their individual care plans. As some of the residents do not communicate with spoken words staff said they look for other ways of seeking the resident’s opinions. They observe their facial expressions and body language to inform them of their likes and dislikes. One member of staff said an example would be if a resident pushed food away this might mean that they don’t like it. Records showed that the home’s admissions procedure had not been followed recently. A resident had moved in very quickly. Staff said that this had caused disruption and anxiety to the residents. This might have been avoided if introductory visits had taken place. The managers and staff had stated their concerns at the time, but their managers had made the final decision. A lot of work has been carried out by staff to resolve the situation and residents are a lot happier now.
Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 6,7 and 9. Quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. All of the residents at the home have an individual plan that is reviewed regularly. Some of the written information in the resident’s individual files needs to be updated to be accurate. This will help staff meet the needs of the residents more effectively. Staff enable and support residents to lead their own lives so they can be independent whenever possible. EVIDENCE: Individual records are kept for each resident. All of the residents have an individual care plan that is reviewed regularly. A sample of the files were inspected and found to contain relevant information about the care of the people who live in the home. The deputy manager and staff said that monthly ‘life style’ meetings are held with each resident. Individual meetings are held with their key worker and sometimes a manager to discuss with the residents their wishes and needs.
Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 11 They decide on different activities and things they would like to do in the future such as holidays. One resident said that they were going on holiday and they go on trips all of the time. They said, “I go to the pub with staff”. Each person has up to date risk assessments that show staff the procedures to follow so they can reduce the risk when working with the residents. A few of the risk assessments were missing and needed to be replaced. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. The residents use local facilities so they can be involved with the community. Staff support the residents to make their own choices as much as possible. This encourages them to be more independent. Social activities are well organised, creative and provide stimulation and interest for people using the service so they can become more confident. Meals are nutritious and balanced and offer a varied diet for residents to maintain their general health and interest. EVIDENCE: The deputy manager said that the residents use the local shop and go out in the evenings. They go for walks and local people say hello and speak to them. On the day of the inspection one resident was going to an art class and another was going out for tea. All of the residents are registered with the local GP.
Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 13 The Home’s menus are based on the known likes and dislikes of the service users. Staff said that they are always trying to find new menus to see if the residents like them and to provide interesting things for them to try. At least two hot meals are provided on a daily basis. Some residents are involved with the shopping. Special diets can be catered for. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 18,19 and 20. Quality in the outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents get personal support when they need it so they can be as independent as possible. The staff monitor and promote the health of residents who live in the home. This helps to ensure their well-being. EVIDENCE: Records showed that the resident’s health care needs are met at the home. Details of health checks, visits to their GP and hospital appointments are recorded in the resident’s individual files. The deputy manager said that the health and welfare of the residents is constantly being monitored. All of the residents have high care needs and not all are able to tell staff if they are unwell so staff have to watch for signs and symptoms. Their health and wellbeing is discussed during staff meetings. There is also input from other services such a community nurses. One worker said that staff always assist them with any assessments they have to carry out. The people who live at the home looked smart and well groomed. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 15 From what the staff said the home delivers personal care to the residents well. Staff said and records showed that any changes of medication or medication procedures are recorded and followed in the home. The deputy manager said that if a resident has a health appointment they take their medical file with them so any changes to medication can be recorded there and then. The deputy manager said residents would be supported to manager their own medication if, following a risk assessment it was found to be appropriate. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 22 and 23. Quality in the outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Complaints are dealt with so any problems are taken care of quickly which helps good relationships to be maintained. Staff know about adult protection so the residents are kept safe. If they had training in the ‘Protection of Vulnerable Adults’ this would increase their skills and knowledge in how to safeguard residents at the home. EVIDENCE: The home has a complaints procedure. This is available to the residents their relatives and carers. The complaints procedure is not available in a form the residents can easily understand. Records showed that there had not been any complaints made since the last inspection. The deputy manager confirmed this. The deputy manager and staff said that all of the staff know the procedure to be followed if an allegation of abuse was made in the home. Staff have not been provided with training in the ‘Protection of Vulnerable Adults’ (POVA). They could not say if a copy of the Local Authorities adult protection procedures is kept at the home. A copy of the companies ‘POVA’ procedures dated the 1.3.06 was at the home, 2 staff had signed to say they had read it. The home has a ‘whistle blowing’ procedure and the deputy manager said that staff have been told about this. Records are made of the resident’s money and what they spend it on.
Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 24,28 and 30. Quality in the outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is comfortable and clean, (a few areas need repairs) so the residents have a pleasant house to live in. Space is taken up in the home for the storage of equipment; this reduces the space available to residents. A computer made available to residents would increase their skills and independence. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 18 EVIDENCE: The home is clean and comfortable Cupboard doors and the blind are broken in the kitchen, it generally looks worn. The home does not have enough storage for all of the equipment needed by the residents. This is restricting the space available in the home and it is makes it look cluttered. The residents’ bedrooms looked very comfortable it showed that staff had worked hard to enable the residents to personalise their own rooms. They had been made individual and comfortable. Staff said that water temperatures are monitored by staff to make sure the water doesn’t get to hot. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 19 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in the outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home has a recruitment procedure to vet staff so the residents are kept safe. Methods used by the home to carry out CRB checks on staff need to be checked with the Criminal Records Bureau to make sure they are adequate. Staff are supervised and get training so the residents are well cared for. EVIDENCE: Records showed that the manager has the relevant qualifications and experience to run the home. One carer said that their relative had ‘”come out of themselves” since they had moved to the home and put this down to the managers hard work. Another carer said that they “ have every confidence in the manager”. A care manager said that the manager has worked very hard to make sure the residents are well cared for. Staff records are kept at a central office of the company who own the home. Records showed that staff are vetted before they are employed. The manager said that all staff have been CRB (Criminal Records Bureau) checked at an enhanced level to make sure they were suitable people to work at the home. A security firm is used by the company to carry out CRB checks on staff the results are then e mailed to the company. The manager and owners of the
Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 20 home do not see the original CRB return record. This procedure needs to be checked with the Criminal Records Bureau itself to make sure this is an adequate procedure. Sufficient staff were on duty during the inspection and the deputy manager and staff said that enough staff worked at the home. Records showed that on other days enough staff had been on duty. The deputy manager said that 3 staff have completed vocational qualifications in the care of adults and another 3 staff are in the process of completing one. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 21 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in the outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The manager has the experience and qualifications to run the home so the residents are well cared for. Resident’s views are sought about how the home is run as much as possible, so they know they are listened too. There are procedures in place to promote the health and safety of the people who live in the home so they are protected and kept safe. A copy of the reports from the regular monitoring visits to the home should be sent to the home so the manager and staff can act upon any issues and improve the service to the residents. The home has a quality assurance system so the service the residents get is looked at and improved. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager confirmed and records showed that they have the relevant qualifications and experience to run the home. Records showed that checks had been carried out on the equipment in the home; such as testing electrical equipment and the servicing the central heating boiler. Fire safety risk assessments had been completed. The fire logbook showed that regular fire drills take place and the manager said that fire instruction is being carried out at the required intervals. Records showed that regular training is provided for staff in fire safety, food hygiene and first aid. The deputy manager said that the home has regular monitoring visits; only one of the reports was seen at the home. Records showed that the home has a quality assurance system. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 23 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 Standard No Score 1 X 2 3 3 X 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 3 X X 3 X Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 24 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. 2. Standard YA4 YA6 Regulation 4 17 Requirement The homes admission procedure must be adhered to. Individual residents files must contain the required information, which is accurate up to date. All staff must receive training in the protection of vulnerable adults, Repair or pelace the kitchen cupboards and blind. The home must have adequate storage space. The registered individual must make sure that the system of carrying out enhanced CRB checks on staff meets the required standards. Copies of the reports from the monitoring visits are lodged at the home. Timescale for action 28/09/06 28/11/06 3. 4. 5. 6. YA23 YA24 YA28 YA34 13 23 23 19 (schedule 2). 26 31/12/06 31/12/06 31/12/06 01/11/06 7. YA37 01/11/06 Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 25 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 YA7 Good Practice Recommendations Social security benefits should be paid directly to residents and residents invoiced for their care fees. Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cramlington Area Office 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 Kilburn Gardens, 53 DS0000000357.V295100.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
