Inspection on 18/06/08 for Kilmar House

This inspection was carried out on 18th June 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/10/2008.

CARE HOMES FOR OLDER PEOPLE Kilmar House Higher Lux Street Liskeard Cornwall PL14 3JU Lead Inspector Helen Tworkowski Unannounced Inspection 18th June 2008 8:50 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 Kilmar House DS0000070767.V362316.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 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. Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kilmar House Address Higher Lux Street Liskeard Cornwall PL14 3JU 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) 01579 343066 01579 343066 Mr Stephen Anthony Corcoran Mrs Nichola Jayne Broadhurst Mr Stephen Anthony Corcoran Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 15. This is a new service. Date of last inspection Brief Description of the Service: Kilmar House is situated in the centre of Liskeard. It is a Grade II listed building. The home is registered to accommodate 15 older people, there are thirteen single bedrooms and one double room. On the ground floor there is a lounge, dining room, kitchen and three bedrooms, two of the bedrooms are en-suite. There are three toilets and a bathroom and toilet, with a hoist. There is also a laundry room. There is a lift in the main house to the first and second floor; on the first floor there are three bedrooms and a toilet. On the second floor there are a further three single bedrooms, a double bedroom and a bathroom with a walk in shower, and a toilet. This area is accessed by stairs. On the ground floor of Kilmar House annexe there are two single bedrooms and a bathroom. This part of the house can be accessed internally from the first floor via a staircase, though is more readily accessed across an external courtyard. On the first floor of the annexe there are two single bedrooms, one of which is en-suite. There is also a staff sleep over room with a shower, and a toilet. There is a level access courtyard garden to the rear of the house, and a steep garden, which may be difficult for people with mobility difficulties to use. Information about the home (the Statement of Purpose and Service User Guide) is available in the office of the home, in the entrance hall, and there is a copy of the Service User Guide in each of the bedrooms. Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 5 The fees of the home are between £308 and £360, the fees do not include chiropody, hairdressing, clothing, news papers or toiletries. Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means the people who use this service experience good quality outcomes. This inspection was the first inspection of Kilmar House since Mr Corcoran and Ms Broadhurst purchased the home. The inspection was unannounced, and took place between 8.50 a.m. and 5.50 p.m. Mr Corcoran was present at Kilmar House throughout our visit to the home. As part of this inspection we looked around most of the house- all of the communal areas, and some of the bedrooms. We spoke with three of the people who live at Kilmar House and looked at their care records. We spoke with staff and with Mr Corcoran. We looked at the system for giving medication, at the staff files, and at information on health and safety. We sent surveys to six of the people who live at Kilmar, five surveys were returned; five were sent to relatives of people who were unable to complete their own form, three surveys were returned. Six surveys were sent to care staff, all of the surveys were returned. We also received a completed questionnaire from Mr Corcoran. This provided the Commission with information about how Mr Corcoran assessed the quality of the service at Kilmar House. What the service does well: The people who live at Kilmar House and their relatives believe that they are receive a good service. Comments include: • • • • “The owners took over the running of Kilmar House last December and have already put into practice a feeling of hominess and comfort, and a feeling of a family unit.” “The staff are very friendly and caring always “ask” the clients and not “tell” them on different tasks. They allow the clients to make decisions”. “Staff are supportive of both their residents and their families”. [Staff are] … “very well trained and managed by Steve and Holly”. We found that the Manager, Mr Steve Corcoran, gets to know and meet people before they move, and that Mr Corcoran’s provides much of the information they need to know before they move. Staff know about most the needs of the people they care for and support. The people at Kilmar House feel that they are treated with respect and dignity and Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 7 families are kept informed, and visitors are made welcome. Medication is generally well managed. People feel that they have enough to do in the daytime, and a new patio area has provided another pleasant sitting area. The house is clean and comfortable, and people have been involved in choosing the décor. Visitors to the home have commented on the fact there are never any unpleasant odours. Meals are well cooked and are enjoyed. The people who live at Kilmar House, their relatives and the staff all know how to raise a concern, if they should want to. Staff have received training in relation to how to recognise abuse and feel that the management of the home is approachable. There are enough staff, who are well trained, well supported and managed. One member of staff commented, “The Manager is always around and therefore available for support and guidance”. What has improved since the last inspection? This is the first inspection since home was purchased by Mr Corcoran and Ms Broadhurst, and managed by Mr Corcoran. Mr Corcoran has identified a number of areas where improvements have been made, these include: improvements in the décor and bathing facilities better care planning and involvement of families changes to meal times so that they better suite the people at Kilmar House more staff training a new office has been created for staff care to use the medication system has been improved The home is well managed and people have noticed the improvements, one relative commented, “…the overall improvement since the new owners is remarkable, I would not consider moving my mother to any other care home. What they could do better: Assessment are made before people move to Kilmar House, however these are not always written down in any great detail. This means that things are more likely to be missed when the information is used to develop a plan of care. This is particularly important where people have more complex needs. There are care plans and though they lack detail. The lack of detail may not affect the quality of care for people who do not have more complex need, or who are able to explain their own needs. However it is more critical to ensure a good standard of care for people who are not able to direct their own care of who have more complex needs. Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 8 The medications system is generally well managed, however there was a lack of proper arrangements for where an individual was considered to be selfmedicating. We found that whilst most of the required checks had been made on prospective staff, one of the checks had been omitted. The people who live at Kilmar House could be vulnerable to people who are not suited to the work, and the utmost care must be taken to ensure that no one starts work in the home before the relevant checks are completed. The home is generally well maintained and further improvements are planned. We found that risk assessments that should help identify what actions need to be taken to keep people safe have not yet been completed. This included the risk assessment in relation to fire and in relation to Legionella infection. 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. The summary of this inspection report can be made available in other formats on request. Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 9 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 Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 (Standard 6 is not applicable) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People thinking of moving to Kilmar House can be assured that the Manager will meet with them, to get to know their needs. However this information is not always well recorded, and staff are not fully aware of all needs. EVIDENCE: We looked at what knew about people who had recently come to stay at Kilmar House. We found that there was very little written down about what the individual’s needs were. We spoke with Mr Corcoran about this and he explained that he had been to see the both people, and one of the individuals and their relatives was able to confirm that this was the case. One relative responding to the survey said “My mother was interviewed before she went to Kilmar as to suitability for both her and the home and other residents all her requirement have been met”. One person living at Kilmar House said: “The manager visited me and gave me all info before I decided to come here.” Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 11 We spoke with one of the staff about what she knew about one person’s needs and why the person used certain equipment, the staff did not know and there was nothing on the assessment to indicate why this equipment was used. From our discussions with staff it was clear that this individual had some problems remembering things, however there was no information about their needs in this area. Written information helps ensure that needs are not missed and helps to towards providing consistency in care. We talked with the Manager about the contract or terms and conditions given to a person who had recently moved to the home. The documents contained no reference to which room the contract related to, or the fact that the room was shared. We discussed with the Manager the importance that people sharing rooms should be clear about how decisions will be made about who they share with. Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at Kilmar House are given the help and support they need, however the records to ensure that nothing is missed and that support is given in the way people prefer, are lacking in detail. Medication is generally well managed however there are no proper systems to ensure that where people self medicate this is safe to do. EVIDENCE: Five of the six people who live at Kilmar House, and who responded to the survey said that they always received the care and support they needed, whilst the sixth person said that this was usually the case. One person commented that: “I would like to add my own comment – that is I find the present ownership of Kilmar House are very efficient, caring, helpful and understanding. Above all previous proprietors in all the years I’ve been here. I give them 105 ”, and one of the relatives said “Everything that Mother throws at them is dealt with in a competent friendly and humorous manner”. Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 13 We looked at the information that the home have to explain how needs are to be met. We found that there was information, however that the information was very general and lacking in detail, and the actions staff are to take to meet needs. It is important that the information is detailed and sets out, in detail, how needs are to be met. This information should reflect the personal wishes and preferences of the individual. Many of the people who live at Kilmar House can tell staff about the way they need things done, and are happy with the help they receive. However we believe that it is important that there is a good record of the care to be provided. Such records ensure that those people who are not always able to say get the service they want, and that support is consistent and, want and needs are not missed. All six of the people living at Kilmar House who responded to the survey said that they receive the medical support they need, one person commented, ”They are very good at getting the doctor out to see me when I’m unwell”. We looked at the system for managing medication and watched a member of staff administer medication at lunchtime. We observed that people were given a drink with their tablets, and that where people had tablets they could have for pain- the individual made this decision. This is good practice and is an important aspect of encouraging people to maintain their independence. We found that the system for recording what medication was in the home and what had been given, were in good order. We were told that medication was audited every month. One area of concern was that we were told that one person administered his or her own medicines. We asked to see if any assessment had been made to see if the individual had the ability to do this, and were told that no assessment had been done. This was of particular concern given that the individual was thought to have some problems with memory. We were told that the individual did not keep their own medication, but that they were given their medication in a daily pill box, they then took the tablets and returned the pill box to staff. We were told that a relative had filled these boxes, prior to the individual coming to stay at the home. When we looked at the carrier bag of pillboxes, one of the tablets had come out of a box and was loose in the bag. It was not clear what was in the pillboxes. We asked staff how they knew what tablets the person was on and was told that this information was copied from a repeat prescription form. This document was no longer on site, as it had been returned to the family with a copy being taken. We looked at the medication records and saw that staff were signing to say that they were administering particular drugs. Staff could not be sure what was in the boxes was what they were handing to the person to take. Also if the individual was competent to deal with their own medication then staff were not administering the medication. Individuals have the right to manage and administer their own medication. Their ability to do this must be assessed, to ensure that they maintain as much independence as possible, and get the help they need. Staff Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 14 must not administer medication unless they are certain it is what has been prescribed. Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people at Kilmar house enjoy a good standard of meals. They are treated with respect by staff. EVIDENCE: The information provided to people living at Kilmar House shows that activities are organised for each morning at 11 am and 2 pm. One relative commented about Kilmar House that it: “…Allows freedom of choice for their evening and breakfast meals. They allow them to join in, or not on any activities they might be done”, another person living at Kilmar House said “Plenty of activities are offered but it’s my choice if I want to do them or not”. Mr Corcoran said that they had recently created a patio area to the rear of the house, and that this area was well used. We spoke to the people who live at Kilmar House and asked them about how staff treated them. We were told that people were treated with respect and dignity. All six people responding to the survey said that staff listened and acted upon what they said. One member of staff said in a survey “The service exemplified the idea of high quality care, is tailored to work with the needs of Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 16 individual service users. It centres on assisting individual to achieve as much independence as possible, offers choice to be made in all aspects of personal care, dietary requirements and modes of daily living activities. It operates by giving individuals freedom of expression within both the environment and current legislation”. There is a pay phone in one of the hallways, though Mr Corcoran said that many people prefer to have the handset taken to them in their room. We spoke with visitors and were told that they were always made welcome. One relative commented: “….Always receive a call very soon after an event – even if its just a minor fall and details of action taken and treatment given” and an other person said “Kilmar House has contacted me whenever Mother expressed a wish to speak to me this has also applied to her friends.” People were still eating breakfast when we arrived. The tables were well laid and the room looked inviting. We spoke with the cook and saw the food that was offered at lunchtime. The meals were well cooked and plates were returned to the kitchen empty. Comments from people living at Kilmar House about the meals included: “I always have a clean plate- no complaints”, “Good portion size. Food is nice and hot”, and “If I don’t like it I have something else”. Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Kilmar House are well protected from abuse and are able to raise concerns if they feel they need to. EVIDENCE: There is information about how to complain in each of the bedrooms, one relative said in a survey that” At my first enquiry I was given an information pack which has details of the complaints procedure”. All of the relatives and people living at Kilmar House responding to the survey said that they knew how to complain, one person said that if he had a complaint then he knew who to speak to, “Yes, the governor”. All six of the staff responding to the survey said that they knew who to speak to if any one raised a concern. We discussed Safeguarding with the Manager and we were shown the Safeguarding Policy, this sets out how people in the home will be protected from abuse. We also saw evidence that staff were to have further training in relation to protecting people from abuse. We looked at the system for looking after money for people living in the home. We found that there were records of all transactions and receipts were kept. Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Kilmar House provides clean and comfortable accommodation. EVIDENCE: As part of this inspection we looked around all of the communal areas and saw some of the bedrooms. The house was clean and there were no unpleasant odours, one of the relatives visiting the home commented that she had looked around much of the house and was pleasantly surprised to find that there were no unpleasant odours anywhere. Five out of the six people living at Kilmar House said that the home is always fresh and clean, whilst a sixth person said that it usually was. Mr Corcoran said that since he had taken over the management of the home a number of carpets had been replaced and rooms had been redecorated. Mr Corcoran said that the people living at Kilmar had been consulted about the colours that would be used. In information supplied to the Commission in a Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 19 questionnaire, Mr Corcoran has said that they have employed a cleaner. Other improvements identified were the provision of a walk in shower and a special hairdressing sink. We checked the temperature of hot water in a number of areas of the home; we found that there were thermostatic valves to regulate temperature. We discussed with the manager the need for there to be risk assessments in place to manage the risk where these thermostatic valves can be over-ridden. We looked at the laundry area. Mr Corcoran said that this area would be for development sometime in the future. We noticed that the laundry is used to store items such as staff uniforms. We discussed with Mr Corcoran the importance of keeping a clear separation between clean and soiled items, so that if there is an outbreak of illness in the home, the spread is minimised. We would recommend that the advice of professional expertise, such as Environmental Health or the Health Protection Agency, is sought in relation to any changes to the laundry area. Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people at Kilmar House are supported by well trained and competent staff. EVIDENCE: We surveyed approximately half of the care staff at Kilmar House. We found that staff felt that they received the training they needed to do their work. Comments from staff included: “We have had lots of training in the last few months and there is lots more booked/planned. The manager is always open and response to any request that staff have for further training” and “With Mr Corcoran’s NHS background, he is passionate about frequent training and keeping abreast of new working methods, safe practice and current legislation. In the six months that they took over the proprietorship of Kilmar House, he instigated up to date training courses as soon as the could practically, and more are in the pipeline”. We saw that there information about future training courses on the notice board and that there was information on file about the training on staff files. Comments from relatives included: “The staff are NVQ trained/training they are all well presented, willing to listen and conscious of their residents needs”. We were told that there are two care staff on duty at all times, when we looked at the rota we noticed that there were times when this appeared not be the case. Mr Corcoran explained that on these occasions he was on duty. We advised that where Mr Corcoran is providing care this should be shown on the Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 21 rota. We noted that the people at Kilmar House were well dressed when we visited and that there was no evidence of any lack of care, and therefore believe that there are sufficient staff to meet needs. All of the staff responding to the survey said that there were always sufficient staff, staff commented “Two member of staff on duty to attend to cover needs, and Mr Corcoran is a visible presents, enlarging complement of care providers in relation to total of service users”. We looked at the way staff were recruited from the information on file. Mr Corcoran confirmed that he had recruited one staff since he had taken over the management of the home. We found that there was evidence that references had been taken to check the suitability of the individual. A check had been made of any criminal record that the person might have had. In addition a check had been made to see if the person had been included in a list of people who are not suited to work with vulnerable people, a “POVA check”. We found that this had been recieved, but not until after the person had started work. No one may work in a care home until this check is made, and no one may work unsupervised until a check of their criminal record has been made. Staff said that they felt well supported in their work, comments included: “The staff work well as a team and all know their roles within the team. The staff are passionate about what they do and regularly go above and beyond for residents as all genuinely care” and “The manager is always around and so I get lots of support. I have now started my NVQ due to the support of my manager”. Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Kilmar is generally a well managed and organised home. The manager, Mr Corcoran provides staff with a clear sense of direction. Further checks in relation to safety are required to ensure that no one is put at risk of being hurt. EVIDENCE: Mr Corcoran has been the Registered Manager of Kilmar House since 20th December 07. We found that the home is well managed. Relatives of the people who live at the home commented: “The owners took over the running of Kilmar House last December and have already put into practice a feeling of hominess and comfort, and a feeling of a family unit. I think they have made it substantially inviting and comfortable and I cannot see what else can be done for the clients of the home, or their needs” and “…the overall improvement Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 23 since the new owners is remarkable, I would not consider moving my mother to any other care home”. Comments from staff included: “Mr Corcoran is a very dedicated manger who I feel enhances the lives of the service users in the short period of time that he has been there. He also re-decorated numerous areas of the home to a high standard”, and I would like to add for the records that it is an absolute pleasure to be employed at Kilmar House and under Mr Corcoran’s leadership I am more proud than before of my association with the home”. It was clear that Mr Corcoran’s management had made a significant in the way the home is run. From our discussions with Mr Corcoran and from our observation it was apparent that there had been significant improvements in the last six months, though Mr Corcoran had plans for many further improvements. We reminded Mr Corcoran of the need to inform the Commission of significant events, including any allegation of misconduct of staff in the home. We discussed quality assurance with Mr Corcoran, and was told that they were told that they were in the process of designing a system and drafting questionnaires. We looked at the way the home was kept safe for both the staff and the people who live at Kilmar House. There was a fire risk assessment, however this new document had not been completed. The Manager has said that he is using the one produced by the previous owner. We looked at the checks made of the fire system, and found that these were generally being made, thought weekly checks of the fire alarm were last made on 11th May 08, one month previous. During the tour of the building we noted that one of the external ramps from a fire exit was sagging, and might pose a risk. We also discussed with the Manger the need to ensure that a Legionella risk assessment is completed and identified checks are completed. Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 24 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 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 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 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1) Requirement New people must only be admitted on the basis of a full assessment, to which the prospective resident, his/her representatives (if any) and relevant professionals have been party. There must be a plan of care generated from a comprehensive assessment drawn up with each resident. This document must be insufficient detail to provide the basis for the care to be delivered and reflect the wishes and preference of each the person. The Manager must ensure that where people wish to self medicate, they are provided with the support they need, that has been identified through a risk assessment. No one may work in a care home without a check of the Protection of Vulnerable Adults list. Once this check has been completed then a person may only work under supervision until a Criminal Records Bureau check has been completed. DS0000070767.V362316.R01.S.doc Timescale for action 01/08/08 2. OP7 15 01/09/08 3. OP9 14 (4)c 01/08/08 4. OP29 19 01/08/08 Kilmar House Version 5.2 Page 26 5. OP38 13 (4) c Risk Assessments must be completed and action taken to ensure that both staff and the people are Kilmar House are safe from unnecessary risks. This must include an assessment of risks posed by scalding and from Legionella infection. 01/09/08 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 OP2 Good Practice Recommendations Contracts or terms and conditions should make it clear which room is to be occupied. The document should also make it clear in the case of double rooms exactly how arrangements for sharing will be managed and ended. Advice should be sought to ensure that the management of laundry and general hygiene is organised to minimize the risk of the spread of infection. Where the Manager is providing care and support then this should be marked as such on the rota. It should be clear who is providing care in the home, so that there can be clear accountability. 2. 3. OP26 OP27 Kilmar House DS0000070767.V362316.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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