Inspection on 08/12/06 for Kilmory

This inspection was carried out on 8th December 2006.

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 no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kilmory 13/12/05

Kilmory 08/08/05

Kilmory 06/01/05

Kilmory 05/08/04

Kilmory 16/03/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

Heather House Nursing Home

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Kilmory Beech Hill Headley Down Bordon Hampshire GU35 8NL Lead Inspector Nick Morrison Unannounced Inspection 8th December 2006 09:30 Kilmory DS0000012091.V319869.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 Kilmory DS0000012091.V319869.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. Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kilmory Address Beech Hill Headley Down Bordon Hampshire GU35 8NL 01428 712177 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) Robinia Care Limited Care Home 6 Category(ies) of Learning disability (6), Sensory impairment (6) registration, with number of places Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2005 Brief Description of the Service: Kilmory is a large detached house that stands back from the road at Headley Down, Hampshire. The home provides accommodation for six younger adults who have learning disabilities. The residents are accommodated in four single rooms and one shared room. There is a large lounge, with an adjoining small conservatory currently used as the office, and a large conservatory to the rear of the lounge, that is used as an activities room/dining room. There are gardens and patio area to the rear of the property and a lawned area to the side. The home is owned and operated by Robinia Care Limited, an organisation that has been a registered care provider since 1995. Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report represents a review of all the evidence and information gathered about the service since the previous inspection. This included a site visit that occurred on 8th December 2006 and lasted six hours. During this time the Inspector toured the premises, looked all service users’ files and met with two of those people. All records and relevant documentation referred to in the report was seen on the day of inspection. The Inspector spoke with the Manager and two members of staff. The Inspector was unable to communicate sufficiently well with service users for them to comment directly on the service provided, but was able to observe their responses during the visit. Current charges in the home were not available at the time of the inspection. What the service does well: What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 6 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 Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 7 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users benefit from having their needs assessed prior to moving into the home. EVIDENCE: Service users’ files showed that they had assessments that had been completed prior to them moving into the home. The assessments were thorough and covered a full range of need areas. There was evidence on file that the families and Care Managers of service users had been involved in the assessment process. Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from being supported to make decisions but would benefit further from having care plans and risk assessments that clearly identify their needs. EVIDENCE: Care plans were in place for each service user. Since the new manager has been in post she has begun to review the existing care plans and is also aiming that, as from now, the care plans will be reviewed on a monthly basis. There was evidence that families and Care Managers had been involved in writing care plans and they had signed to say they agreed with the plans in place. The format for the care plans was good and resulted in clear care plans for each area of need. One service user has been diagnosed as being an MRSA carrier, but there was no reference to this in her care plan. Staff on duty on the day of inspection knew that someone in the home was an MRSA carrier, but they were confused Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 9 as to which service user it was. This is partly due to a lack of information on care plans. Service users were supported to make decisions for themselves despite their communication difficulties. Staff were skilled in communicating with individual service users and care plans recorded some of the ways in which each service user communicated. There were records of how people had made choices in the past and information was used to build up a profile of how each person communicated. Individual risk assessments were in place in the home and the format used was thorough. Risk assessments were used to support service users to take part in activities in a safe way so that the potential risks were identified and managed. However, the risk assessments were not all up-to-date and were not kept under regular review. Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from support to take part in activities and to be part of the community, have their rights recognised and to maintain contact with their families and friends. They also benefit from having a healthy diet. EVIDENCE: The home has an activities programme in place for all service users based on their interests. This includes making use of local day services and planned activities within the home and within the wider community. Service users were able to choose which activities they were involved with or were able to opt out of any activities they preferred not to do. Each service users had a planned programme in place and, on the day of the inspection visit, all service users were undertaking activities according to their programmes. The home has recently begun to keep records of activities service users have participated in Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 11 and these records showed that staffing was arranged to support service users to undertake their activities. A visitors’ policy was in place and service users were encouraged to have visits from friends and families at all times. Records showed that service users had regular visitors and information was kept for each person so that staff were able to support them in maintaining contact with their friends and families. During the inspection visit the Inspector observed staff interacting with service users and they behaved in a respectful way and were aware of the rights of service users. Staff respected service users’ privacy by knocking and waiting for an answer before entering their rooms. Staff interaction with service users was positive throughout the inspection. Service users observed appeared to be happy with the food provided in the home. Menus demonstrated that the diet was varied and nutritious. Individual preferences and dietary needs were considered in the writing of menus and staff offered service users options for their meals for the day. Service users were supported to eat and make mealtimes a social occasion. Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from receiving personal care in the way they prefer and from having their physical, emotional and medication needs met. EVIDENCE: Details of the support each person required were clearly recorded on care plans and staff spoken with were clear about what support each person required. Care plans and records demonstrated that service users’ healthcare needs were regularly monitored and that they were supported to access relevant healthcare services as necessary. This included emotional health needs and the care plans seen, and staff spoken with, confirmed that the home had a very positive approach to responding to difficult behaviours in the home. This was supported by good staff training. There had been a requirement from the previous inspection that the weight of each service user should be monitored regularly and that records should be Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 13 kept. The records were in place at the time of this inspection visit and were kept up-to-date. Medication in the home was well managed. Accurate records were kept of all medication coming into and going out of the home as well as all medication administered to service users. The home had a comprehensive medication policy in place which staff were aware of. There were clear guidelines in place where service users required ‘as and when’ medication, and these had been devised and agreed with GP’s. All staff involved in administering medication had received relevant training and understood their responsibilities within the process of administering medication. All medication was appropriately stored in a medication cabinet. Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from having information on how to complain but would benefit further from being supported by staff who are trained in identifying and responding to incidents of suspected abuse. EVIDENCE: There was a clear complaints policy in place, which was available to each service user. Service users were encouraged to highlight any issues they were not happy with and these were recorded and responded to. Records were kept of any complaint made. There had been no recorded complaints since November 2004. The home has adequate policies in place regarding responding to issues of potential or suspected abuse. Some staff at the home had had adult protection training, but three staff had received no training in this area. The home has a new, updated Adult Protection policy in place and all staff had signed to say they had read and understood it. Care plans contained guidelines on preventing self-harm where necessary. Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users would benefit from the home being decorated and from a more comprehensive approach to infection control within the home. EVIDENCE: The home was comfortable and planned around the physical needs of service users. The amount of living space within the home was adequate for the number of people living there and the home benefited from good natural lighting and ventilation. All parts of the home were accessible to service users and a passenger lift was provided. Furniture provided in the home was comfortable and of good quality. Records showed that maintenance was monitored regularly and, except where otherwise stated elsewhere in this report, issues were responded to in good time. The paintwork in the home was dammed and in need of repainting. On the day of the inspection visit there was a decorator undertaking some painting. Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 16 The home was not unclean but more attention needed to be given to cleanliness and hygiene in some areas. Staff had received regular training in infection Control and liquid soap, paper towels and alcohol gel were available throughout the building. However, there were ordinary towels in some bathrooms and the Manager acknowledged that these needed to be taken away and not used. The laundry area was in need of cleaning. A good and comprehensive cleaning schedule was in place, but there were gaps where some areas had not been cleaned on a regular basis. The laundry area had not been cleaned for ten days. The home’s Infection Control procedures were incomplete as pages were missing from the document. The only thing covered by the pages available was an explanation of how staff should wash their hands. The fact that one service user carries the MRSA virus means that the home should be more conscientious about infection control. Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from being supported by well trained staff but would be better protected by improved recruitment practices within the home. EVIDENCE: Of the eight staff in the home, one had an NVQ 3 and seven were undertaking NVQ training at the time of the inspection visit. The Manager has an NVQ4. Regular staff training was taking place and records were kept to demonstrate this. The company has a comprehensive ongoing training programme in place and staff spoken with said it was easy to get onto courses they wanted to do and that the quality if the training was good. Most of the recruitment records in the home showed that the home’s recruitment policy was followed. However, there was one member of staff who had begun working in the home in June 2006 and the records for her were incomplete. She began working in the home six weeks prior to her Criminal Records Bureau (CRB) check being in place. There had been no Protection of Vulnerable Adults check in place and there was also no risk assessment Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 18 covering the absence of the CRB check. Training records showed that for some of these six weeks this member of staff was undertaking training and not working in the home, but there was a period of four weeks where she appeared to be working in the home without appropriate checks in place. Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a service that is responsive to their views but are not protected by the home’s management of health and safety issues. EVIDENCE: The home has not had a permanent Registered Manager in place for nearly a year. This has clearly resulted in the management of the home being adversely affected during this time. Staff supervision, health & safety, infection control and the updating of risk assessments and care plans are some of the areas that have suffered from the lack of management. The home appointed a new manager in November 2006 and she was on duty at the time of this inspection visit. She is not yet registered as the manager and needs to make a Registered Manager application without delay. She does Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 20 have a background in care services, including management roles, and is currently undertaking a NVQ4. The work she has done in the short time she has been in post demonstrates that she has an ability to identify and respond to issues that need addressing. The lack of management of the past year means that there are many aspects of the service that need to be addressed and improved. The home’s approach to quality assurance is effective and appears to have survived the lack of management support in the home over the past year. A comprehensive quality assurance system was in place and views were regularly sought from service users and their families. Health and safety issues have not been well managed in the home over the last year while they have not had a permanent Registered Manager. The new manager, who has experience and qualifications in health & safety, has already begun to identify and address some of the shortfalls in the short time she has been in post. The company’s own health & safety report on the home is two years old and out of date. There were workplace risk assessments in place but on close examination it was clear that these were general risk assessments that had not been adapted so that they were specific to the home. Some staff had signed to say they had read and understood the risk assessments. Using one of the risk assessments as an example it became clear that, of the two members of staff on duty at the time of the inspection visit, one had not read or signed to say they had read the assessment and the other had signed to say they had read the risk assessment but was not able to demonstrate this by explaining the control measures in place for that particular risk. The home’s Control of Substances Hazardous to Health (COSHH) assessment was out of date and needs reviewing. There had been some incidents over the year that had adversely affected the health and well-being of service users (e.g. a diagnosis of MRSA) that had not been reported to the Commission for Social Care Inspection. Reporting to the Commission had been sporadic and the new Manager acknowledged this and explained that she was clear about what needed to be reported. The new manager had identified that the existing fire risk assessment was out of date when she arrived and she has since redone and updated this. The home had recently had an inspection from the company they have a service agreement with. As a result of the inspection there were two fire extinguishers that had been identified and labelled as “obsolete” and in need of an upgrade. The manager had reported this to the Provider’s maintenance department, but this request has not yet been responded to. There is also a strip around the frame of the fire door on the landing that is peeling off and needs replacing. The Environmental Health officer had inspected the home and had asked the home to provide health and safety information in other languages as there was a perception that some overseas staff had not easily understood detailed information that was written in English. This has not yet been acted upon. The home should further consider this issue because those staff may not understand other important information in the home such as assessments, care plans, risk assessments, training information, medication instructions and other important information. Service users and staff may be at risk if people Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 21 have not received important information in a language they can easily understand. The new manager has a background in health & safety issues and demonstrates an understanding of the scale of health & safety shortfalls in the home. She has shown that she is able to identify those shortfalls and put an action plan in place to rectify them. She has also reported that the Provider is developing a new health & safety system that is due to be implemented in 2007. Nevertheless, there are still a number of issues that remain outstanding at the moment and have resulted in requirements being made within this report. Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 22 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 X 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 X 29 X 30 1 STAFFING Standard No Score 31 X 32 X 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 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 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 1 X Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 23 No 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 3 4 5 6 Standard YA6 YA9 YA23 YA25 YA30 YA34 Regulation 15 13 18 16 16 19 Requirement Care Plans must detail information about all the needs of each service user Individual risk assessments must be kept under regular review All staff must receive training in Adult Protection Infection Control procedures must be in place All parts of the building must be cleaned regularly All relevant pre-employment checks must be in place prior to staff beginning to work in the home The Manager must inform the Commission for Social Care Commission of any event in the home that adversely affects service users The obsolete fire extinguishers in the home must be replaced The strip around the fire door on the landing must be replaced Workplace risk assessments specific to the home must be in place Timescale for action 31/01/07 08/12/06 28/02/07 08/12/06 08/12/06 08/12/06 7 YA37 37 08/12/06 8 9 10 YA42 YA42 YA42 13 13 13 31/01/07 31/01/07 31/01/07 Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 24 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 YA24 Good Practice Recommendations The decoration of the home should be maintained to a good standard Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. Extracts may not be used or reproduced without the express permission of CSCI Kilmory DS0000012091.V319869.R01.S.doc Version 5.2 Page 26 - 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!