Inspection on 11/09/07 for Kilncroft Care Home

This inspection was carried out on 11th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kilncroft Care Home 15/07/08

Kilncroft Care Home 15/08/06

Kilncroft Care Home 05/10/05

Kilncroft Care Home 04/05/05

Kilncroft Care Home 18/01/05

Kilncroft Care Home 22/09/04

Kilncroft Care Home 04/02/04

Kilncroft Care Home 16/10/03

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

CARE HOMES FOR OLDER PEOPLE Kilncroft Care Home 25-29 Ashburnham Road Hastings East Sussex TN35 5JN Lead Inspector Sandra Crosby Key Unannounced Inspection 11th September 2007 9:45 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 Kilncroft Care Home DS0000021149.V348138.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. Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kilncroft Care Home Address 25-29 Ashburnham Road Hastings East Sussex TN35 5JN 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) 01424 434921 01424 435893 Kilncroft@Craegmoor.co.uk www.craegmoor.co.uk Parkcare Homes Ltd Mrs Valerie Riedel Care Home 15 Category(ies) of Dementia (15) registration, with number of places Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is fifteen (15) Service users must be older people aged sixty-five (65) years or over on admission Service users with a dementia type illness only to be accommodated Date of last inspection 15th August 2006 Brief Description of the Service: Kilncroft is registered to accommodate fifteen older people with a dementia type illness. The property is detached and is set in a residential area of Hastings. The property is on four floors. The first two floors are registered as Kilncroft. The top two floors are separately registered to cater for younger adults with a presenile dementia type illness. Both homes operate independently of each other, however the registered manager is responsible for both establishments. The whole building is owned by Parkcare Homes Ltd, which in turn is owned by Craegmoor Healthcare Limited. Local shops and amenities are close by and the home is approximately one mile from the centre of Hastings. The Registered Manager said that the current range of fees is from £363.89 to £450.00 per week. Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection visit was unannounced and carried out on Tuesday 11 September 2007 between 09.45 and 16.00. During the inspection the Inspector spoke mainly with the Registered Manager, the staff on duty, service users and one relative. Some records were seen together with some areas of the home. The atmosphere of the home was welcoming, calm and relaxed, and the home was clean (although odours were noted in some areas) and orderly at the time of the inspection visit. A good rapport between residents and staff was seen. Due to the nature of some of the service, it is difficult to reliably incorporate accurate reflections of the service in the report. The Annual Quality Assurance Assessment (AQAA) documentation completed by the Registered Providers, together with surveys received from relatives and information gained in discussion with the Registered Manager, residents and staff has been used in this report. Information collected in relation to surveys provided comments for example ‘I feel that staff often go the extra mile in standards of care over and above the usual level’, I am very happy with the way my relative is cared for’, ‘I have never witnessed any sort of prejudice from the staff and do not believe the manager would tolerate it’ and ‘the staff are cheerful, patient and kind, visitors are made very welcome. Within the body of this report service users will be referred to as residents. What the service does well: The registered manager with the support of the staff team continues to maintain a calm and orderly atmosphere within the home. It was evident that family members are welcome. Staff were observed to interact very well, and positively, with the residents. Staff spoke positively about the home, and there is a very stable staff team, many having worked at the home for many years. Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 6 The manager is committed to providing a good quality of care for residents but also ensuring that staff are well supported, the home has a good atmosphere. 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 Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 8 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 Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 9 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): Standards 1,3 and 5 were inspected at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents, families and other representatives have all the basic information they require to decide whether the home is for them. (The home does not offer intermediate care and therefore key standard 6 cannot be assessed). EVIDENCE: The Statement of Purpose and Service User Guide were judged as meeting the required standard at the last inspection visit, and the Registered Manager confirmed that these documents provided the information required by regulation. Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 10 The registered company provides appropriate contract/terms and conditions of residence documentation. The Registered Manager confirmed that she carries out pre-assessment visits with written records kept to assess prospective residents prior to admission to the home, to ensure that their needs can be met by the home. The AQAA documentation states that all prospective residents are assessed, discussion is undertaken with families, and a trial period is offered by the home. Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 11 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): Standards 7,8,9 and 10 were inspected at this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ general health and personal care needs are mainly met. EVIDENCE: The individual service users plans seen did not contain up to date reviews, and information that was later seen in the communication book had not been mentioned in the daily records. These issues were discussed with the Registered Manager and she provided a partially completed copy of the new person centred care planning system documentation that the Company were introducing. The Registered Manager reported that staff are to receive training for this system at the end of the month. Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 12 Medication records were seen to be appropriately signed and up to date. Currently it was seen that medications are stored in a locked wooden cupboard, and the night medication was seen stored in the lower cupboard with the stock of personal toiletries for the home. The Registered manager agreed to address this issue. All care staff that administer medication have been trained. The staff on duty at the time of the site visit clearly understood the needs of the residents and treated them with respect and courtesy. However, issues were discussed with the Registered Manager in relation to the lack of personal toiletry items seen in the majority of bedrooms during the accompanied tour of the home. Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 13 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): Standards 12,13,14 and 15 were inspected at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The daily routines and activities provided mainly meet residents’ needs and are flexible. Residents keep in contact with their family and friends. EVIDENCE: The visitor book indicated that the home has many visitors and many are family members and this was confirmed by diary entries of when family members and friends of the residents had visited and if the resident went out with them. Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 14 The inspector observed the residents’ lunchtime, and the food seen was well presented. This was a busy period and it was seen that staff assisted residents to eat their food. When it was later discussed that perhaps extending the mealtime to allow for two smaller sittings, as this would be a way of enabling staff to give the 1-1 attention that was needed, the Registered Manager said that normally it was undertaken as two sittings. The food records for the home were incomplete and the Registered Manager agreed to address this issue. The home has two cats, a rabbit and a guinea pig, and they are very important to the residents. The guinea pig was brought into the lounge during the afternoon and most of the residents indicated that they enjoyed stroking the guinea pig. There is no designated person to undertake recreational activities, and staff undertake as time allows. A bingo session was undertaken on the day of the visit, and staff sat with residents and talked about information in the newspapers. The AQAA documentation states that activities include a monthly visit from the music lady for an afternoon tea dance, and states that a recent improvement is having ‘Memory Corner’ where residents can talk about days gone by. Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 15 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): Standards 16 and 18 were inspected at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ and their relatives’ complaints are taken seriously and investigated. Staff will take the correct action to safeguard residents from abuse. EVIDENCE: The Registered Manager confirmed that there were no recorded complaints or concerns recorded since the last inspection. The AQAA documentation states that any complaints are acted upon very quickly, going through the correct procedure. Staff have received training in relation to the complaints and whistle blowing procedures for the home. Regulation 37 notices are submitted to the Commission as appropriate. The AQAA documentation states that all staff have received training in relation to Safeguarding People and Abuse. Staff spoken with during the visit talked about the home’s policies and procedures and had confidence that management would listen if they had concerns. Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 16 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): Standards 19,21,22,23,24,25 and 26 were inspected at this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a mainly clean and comfortable home with private and communal rooms that meet their needs. However there are areas of the home internally and externally that need repair and this could in time affect the well being of residents. EVIDENCE: The home is generally clean and tidy, although odours were noted in several areas. The home provides a homely environment, however there are areas of the home that are in need of modernising and redecorating. The AQAA documentation states that the outside of the building has been repaired and repainted. Action has been taken by the company to carry out Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 17 work to the front of the premises, however the rear garden area needs urgent attention and the Registered Manager said that action was being taken to address this issue. Around the building it was seen that re-decoration was needed in some areas, and items of furniture needed updating. The Registered Manager said that new carpeting is on order, but has not as yet been delivered and fitted. There were a number of issues raised that needed attention by the maintenance person and the Registered Manager said that she would address these issues. Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 18 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): Standards 27,28,29 and 30 were inspected at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s recruitment procedure and a committed staff team protect residents. EVIDENCE: The inspector observed the staff working with the residents and was impressed with the respect and empathy shown by all the staff on duty. When questioned the staff had a good knowledge of the residents, and gave the residents a personal touch to their care, this is achieved by the established staff team working well together. Two staff files were seen and these contained all documentation as required by Regulation. Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 19 Training is very important to the manager and the staff and all are encouraged to undertake training. The Registered Manager said that staff receive regular supervision from the manager, and the training matrix held in the home identified on-going training for all staff. Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 20 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): Standards 31,33,35,36 and 38 were inspected at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a mainly safe, well-managed home that is run in their best interests and safeguards their rights. EVIDENCE: The Registered Manager is well qualified and holds the Registered Manager’s Award (RMA). Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 21 In relation to quality assurance systems in place the Registered Manager said that the Company sends out questionnaires to relatives, staff meetings are held with information recorded and regular audits are undertaken. Regulation 26, visits are made by a person from the Company and evidence of one of these was seen. The Registered Manager was asked to forward a copy of the Regulation 26 visit reports for the months of October, November and December to the Commission Office in order that improvement made in relation to the issues raised may be monitored. The Registered Manager confirmed that the home currently does not handle resident’s monies. Safe moving and handling equipment needs to be available at all times, the one moving and handling sling seen was broken, and the Registered Manager said that a new one was on order. Kilncroft Care Home DS0000021149.V348138.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 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 2 3 2 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 OP7 OP8 Regulation 15(2)(b) 12(1)(a) Timescale for action The registered person shall keep 30/09/07 the service user’s plan under review The registered person promotes 14/09/07 and maintains service users’ health and ensures access to health care services to meet assessed needs The registered person shall make 14/09/07 arrangements for the recording, safekeeping, safe administration and disposal of medicines received into the care home The registered person shall make 14/09/07 suitable arrangements to ensure that the care is conducted in a manner that respects the privacy and dignity of service users Consult service users 31/12/07 (relatives/representatives) about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including having regard to the needs of service users, activities in relation to recreation, fitness and training External grounds that are 30/09/07 suitable for and safe for use by DS0000021149.V348138.R01.S.doc Version 5.2 Page 24 Requirement 3. OP9 13(2) 4. OP10 12(4)(a) 5. OP12 16(2)(n) 6. OP19 23(2)(o) Kilncroft Care Home 7. OP24 13(2)(c) 8. OP26 13(3) 9. OP38 13(4)(c) service users are provided and appropriately maintained The registered person shall 31/12/07 having regard to the size of the care home and the number and needs of service users – provide in rooms occupied by service users adequate furniture, bedding and other furnishings, including curtains and floor coverings and equipment suitable to the needs of service users The premises are kept clean, 14/09/07 hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance The registered manager ensures 14/09/07 so far as is reasonably practicable the health, safety and welfare of service users and staff – Provide suitable moving and handling equipment at all times RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kilncroft Care Home DS0000021149.V348138.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Kilncroft Care Home DS0000021149.V348138.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!