Inspection on 15/07/08 for Kilncroft Care Home

This inspection was carried out on 15th July 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

Kilncroft Care Home 11/09/07

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Kilncroft Care Home 25-29 Ashburnham Road Hastings East Sussex TN35 5JN Lead Inspector Michele Etherton Unannounced Inspection 15 July 2008 09:40 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.V368615.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.V368615.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.V368615.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 11th September 2007 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.V368615.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. A key unannounced inspection of this service has been undertaken, this has taken account of information received from the service and about the service by CSCI since the last inspection, including an Annual quality assurance assessment (AQAA) completed by the manager. The AQAA has been completed to a reasonable standard but contains areas where more supporting evidence would have been useful to illustrate the activities of the service and future planning. The inspection has also included an unannounced site visit to the care home on 15/7/08 between the hours of 9:40 am and 4:50 pm. During this visit a tour of the premises was undertaken, care and ancillary staff have been consulted with in addition to a relative who has taken time to respond to survey questions about the service, survey responses have also been sought from other stakeholders but these have not been returned to date. The service users at Kilncroft have varying degrees of dementia and as a consequence the majority have been unable to tell us about their experiences, we have therefore used a formal way to observe them during the course of the site visit to help us understand. We call this a Short Observational Framework for Inspection (SOFI). This involved us observing five people who use the service over a set period and recording their experiences at regular intervals, the observation looked at their state of well being, how they interacted with staff and others and the environment. A range of documentation has also been examined including care plans, risk assessments, Medication administration records, staff recruitment, training and supervision records, complaints and accident information. All key inspection standards have been assessed, in addition to those where previous requirements had been issued. What the service does well: The premises are large and offer spacious, comfortable and homely accommodation in a relaxed and friendly atmosphere. Systems are in place to ensure prospective service users are assessed before moving in. Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 6 Service users benefit from having enough staff on duty to support them, staff turnover is low and continuity for service users good, the staff team are well trained demonstrate commitment to their role and an understanding of the needs and routines of the service users in their care, observations of staff practice highlighted many examples of kindness, patience and sensitivity to the privacy and dignity of service users. The home routines promote and encourage service users to retain control of daily routines where possible with opportunities to make choices and decisions on a day-to-day basis. The home is welcoming to visitors. Residents enjoy a varied diet and are able to choose what they eat. What has improved since the last inspection? What they could do better: Infection control measures within the home would benefit from more frequent carpet or floor cleaning in those bedrooms where a problem of odour or soiling exists. There is also a need to ensure that the emptying and cleansing of commodes is confined to designated areas to reduce risk of cross infection and that can be subject to more intense and focused cleaning schedules. We have also made recommendations for improved practice in respect of ensuring staff adhere to agreed moving and handling assessments and that these comply with best practice, that administration of all prescribed external medications is recorded on medication administration sheets (MAR). It is acknowledged that service users are unlikely to have sufficient capacity to make complaints directly, however indirectly they are able to make comments and indicate concerns and distress and a record of this should be made. The staff recruitment procedure is comprehensive but would benefit from the development of interview records to evidence that employment histories and verifications for leaving previous care roles are being adequately explored, Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 7 staff files would also benefit from better quality photographs to aid identification. 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. Kilncroft Care Home DS0000021149.V368615.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.V368615.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): 3,6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective service users have their care and support needs assessed prior to admission to ensure these can be met by the home. An intermediate care service is not provided EVIDENCE: The Statement of Purpose has been reviewed at previous inspections and judged as containing the information necessary to those people seeking a dementia service. Staff observed and spoken with at the site visit demonstrated an awareness of current good practice in the field of dementia care and confirmed they have access to a range of training and expressed confidence that where a specific support need is identified for a service user Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 10 training would be offered staff to ensure they know how to provide appropriate and effective support at all times. Only two new service users have been admitted to the home since the last inspection, discussion with the manager indicates that in both cases the individuals lack capacity and initial contact with the service has been undertaken by representatives, an examination of the records for these service users confirms that they received an assessment of need prior to admission to ensure their care support needs could be met. A relative consulted with during the site visit confirmed that although it had been many years since the admission of their own relative, they recalled being provided with an opportunity to visit and look around and also that some written information had been made available to them about the service, they thought they had enough information at that time to inform their decision regarding admission for their relative and were still satisfied with the decision made. The Home does not offer an intermediate care service and this standard has not therefore been assessed. Kilncroft Care Home DS0000021149.V368615.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): 7,8,9,10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff’ demonstrate a good understanding of the needs of individual service users and how to support them effectively but must ensure they adhere to agreed practice. Service users are treated with respect and courtesy. Arrangements for the administration and recording of medication are satisfactory EVIDENCE: Discussion with the manager indicated that care plans have been developed in a more person centred format but are being updated to take account of capacity issues. Staff demonstrated a good understanding of individuals and there needs and particular behaviours, in consultation staff indicated that they feel well trained to deal with issues that arise and feel confident that the company would provide specialist training to address any gaps in knowledge that arise. Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 12 Care plans viewed had good detail about the individuals and how they like to be cared for, we saw examples of staff encouraging independence and decision making for individual service users in their everyday routines; all the staff observed during the site visit related positively with the service users demonstrating kindness and patience in their communication with them. Staff’ were seen to be observant and responsive to situations treating users with courtesy and respect. Risk assessments are in place for individuals and consideration should be given to ensuring this encompasses the risks’ users may experience within their own bedrooms in particular the suitability of some furniture fittings particularly where these are on items or possessions brought in from the individuals home, this was discussed with the manager at the site visit. During time spent in communal areas with service users we saw some examples of unsatisfactory practice in relation to moving and handling, the rationale for this as explained by staff was unconvincing in two out of the three examples noted and care plans examined did not support any agreed deviation from standard practice, in one case it may not be in the users best interest to follow accepted practice but the rationale for doing so must be clearly recorded and discussion undertaken with significant others. It is recommended that the manager ensures moving and handling within the home is in keeping with current best practice and is carried out in compliance with agreed moving and handling assessments for individuals. Staff reported that users are accompanied to hospital and to all health appointments by staff, a record of health contacts is maintained for individuals. Staff’ were observed correctly interpreting non verbal signs and behaviours by individuals residents and responding accordingly, support around personal care needs was observed to be discreet and respectful of the dignity and privacy of individuals. A relative who visits frequently commented that the care staff: “treat me well treat mother with respect, and the others too, they seem to care about residents theyve got, always look clean , all of them not just my mum” Medication is only administered by trained senior staff members, we observed staff taking time to explain to service users why they were taking medication, and encouraging them to do so, an examination of medication records indicated that these are satisfactorily completed in most cases, although the administration of a prescribed cream for one service user and use of an unrecorded code were noted, the manager has agreed to address these omissions and is recommended to ensure as good practice that all prescribed external medications are recorded on MAR sheets, and that all codes used must have their meaning made clear. Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 13 The Home has addressed previous shortfalls in medication storage and maintains records of storage temperatures; facilities are available for storing medications at lower temperatures. Systems are in place to record the movement of medication in and out of the home. The manager reported that medication is reviewed for users particularly where the home identify this as having an impact on the quality of life they experience e.g. not alert and asleep for long periods. Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are provided with an activity programme that takes account of individual needs and preferences, and should be able to respond to those who need more stimulation. Visitors are made to feel welcome. Service users are encouraged to make choices and decisions in their daily routines where possible and are provided with a varied menu that takes account of their preferences, some would benefit from improved monitoring of fluid intake. EVIDENCE: During the site visit a game of frustration was enjoyed by a group of three service users and a staff member, staff were also observed making use of photo albums and newspapers in engaging and stimulating individual service users. We observed that in communal areas users benefit from access to newspapers, clocks, mirrors and lots of visual prompts to aid orientation and provide stimulation. The atmosphere throughout the communal areas was observed to be relaxed and calm with those capable of independent mobility moving freely between areas. Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 15 The home has developed a memory corner and individual users can go to this area and pick up items that they may be familiar with and aid reminiscence staff reported that they play card games and painting activities, some additional staffing hours are available on two days each week to enable those residents who are able and want to be taken out for a walk or in a taxi to the town. A musical entertainment is also provided. Survey feedback indicates that relatives feel there may be a need for some additional activities although it was unclear what they would like to see developed. Relatives consulted spoke positively of the attitudes of staff and felt their relative benefited particularly from the time staff spent with them chatting and the musical entertainments provided, some service users who have brought their own musical instruments into the home are encouraged to continue playing. We observed that at one time during our tour of the home the Television in the lounge was playing music but had no picture, service users that were alert were looking at the blank screen, consideration should be given to ensuring that if the television is to be used to provide music some visual stimulation should accompany this as clearly users expectations were that if the television is on they should be seeing a picture. Plans to improve the patio and garden area are ongoing and service users are encouraged to help plant and tend to some raised flower beds and planters, users are also encouraged to participate in looking after the rabbit and guinea pig, and enjoy the presence of the cat. The home has developed picture reference cards to aid menu choices, we observed users being advised of what food they were having for lunch and a record is made of comments they make about food choices. Service users were asked whether they wanted extra food, and those who needed it were supported discreetly to eat their meals at their own pace, gentle prompting was offered to others, a bowl of fresh fruit is available in the lounge area for service users to access. We saw examples of staff promoting independence for users by ensuring plate guards are in place to aid users in managing their food, one lady was provided with her glasses by staff to enable her to see her food better. Consideration should be given to offering condiments with meals as these are not offered currently. Drinks are provided to service users throughout the day and we observed juice drinks being offered to users late morning during our visit, however, we noted from our observations that drinks brought round by staff were provided only if a user indicated they would like one, for those users who may sleep more, be passive or withdrawn there is a risk that they may be routinely overlooked and consequently drink less than they should, consideration should be given to ways in which drinks can be made more accessible to all service users. Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 16 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): 16,18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are listened to, staff’ are responsive and act upon any concerns expressed by service users but recording in this area could be improved upon. Systems are in place to safeguard service users from harm EVIDENCE: The complaints record shows only one complaint received since the last inspection, with none from residents, A complaints procedure is displayed, whilst it is unlikely that residents would make complaints directly the home is already recording client comments in respect of food and is recommended to similarly consider recording comments of concern or complaint made by residents, whilst these may not always instigate an investigation, they are important for monitoring states of being and whether common themes occur within user concerns that may require further investigation. A relative present during the site visit confirmed their awareness of the complaints procedure, and stated that they felt comfortable about raising concerns with the manager, they understood they could take their concerns outside of the home if they were not addressed, they commented that: Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 17 “I’ve never had to make a complaint, if I had any concerns I would raise them with the manager, if she didnt deal with them I would go higher, I think the complaints process is displayed in the home I would read that”. Staff reported they had all received POVA training they all had an understanding of abuse and the whistleblowing policy, they had an awareness of the need to flag up concerns with senior staff immediately and were clear that in the event of these concerns not being addressed could take these concerns elsewhere. Service users benefit from a continuity of staffing within the home, and a comprehensive recruitment programme to ensure the fitness of prospective staff. Consultation with staff highlighted a good level of job satisfaction and a positive view of the work and the people they are there to support. Staff report that they feel well supported by the management team, and are provided with relevant and up to date training to enable them to work effectively with users. The manager and some senior staff demonstrated an awareness of recent changes in legislation that impact on the service users in respect of capacity and deprivation of liberty. The home does not manage any monies on behalf of residents. Kilncroft Care Home DS0000021149.V368615.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): 19,20,21,22,24, 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Services users live in a pleasant and homely environment that will benefit from planned upgrading and the implementation of improved infection control measures EVIDENCE: The company has responded to previous requirements regarding shortfalls identified within the environment at previous inspections. In addition a property survey to list needed works has been undertaken. Planned works to upgrade individual bedrooms with replacement furnishings and new vanity units is still to commence. The downstairs communal areas have been re-carpeted throughout and dining room furniture replaced. Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 19 A review of the fire log indicates that fire detection and fire fighting equipment is subject to routine servicing and testing, and staff are receiving regular fire training and drills, it is recommended that the home progress an outstanding improvement to the fire precautions in that an in tumescent strip be installed on the identified doors. The Home manager confirmed that equipment for the use of service users is being maintained regularly and samples of current servicing certificates were noted in respect of the Hoist and Parker bath. Bedrooms viewed although clean and tidy are Spartan in appearance and lacking in homely touches some are more personalised than others with personal effects and photographs. All will benefit from upgrading. The manager was reminded of the need to risk assess bedrooms and the furniture within them including that brought in by service users, this was particularly highlighted in a bedroom where furniture brought into the home by a service user has prominent metallic fittings on the furniture that could pose a risk of injury. Communal lounges and the dining area in particular are pleasant and homely, and the manager was urged to ensure that any upgrading is mindful of the need to retain the homely ambience and layout of the downstairs area which works very well and adds to the atmosphere within the home. The home has ancillary staff to undertake laundry, cleaning and cooking on most days although the cleaner is not available on Fridays, Saturdays and Sundays. The home is maintained to a good standard of cleanliness with a relative particularly commenting on the lack of unpleasant odours in the home, infection control measures are in place with liquid soap and paper towels located in all toilet and washing areas, staff were observed washing hands. A tour of the premises highlighted two bedrooms where there is a need for more frequent carpet and floor cleaning, consultation with care and cleaning staff highlighted that commode cleaning is not confined to any designated bathroom and toilet and as such this arrangement could compromise infection control within the home, the likelihood of cross infections would be significantly reduced by strict designation of one or two areas only for the emptying and cleansing of commodes and the routine deep cleanse of these areas after such use, these shortfalls have been discussed with the manager at the site visit and a requirement issued for them to be addressed. With the absence of a sluice facility the manager may wish to consult with the health protection agency to ensure the most effective management of commodes is implemented within the limitations of the home resources. Laundry arrangements allow for a good separation of dirty and clean laundry although a large sink which could be used for hand washing is close to where Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 20 clean washing is stored and could compromise the cleanliness of laundry, the home may wish to look at this when the refurbishments are undertaken. Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 21 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): 27,28,29,30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is enough well trained staff available to support current levels and needs of service users. Some improvements in recording would enhance and add clarity to the comprehensive recruitment procedure in place. EVIDENCE: On the day of the site visit in addition to ancillary staff dealing with cleaning, laundry and cooking there were three care staff as well as the home manager, consultation with staff and a relative indicated that this is the normal level of staffing which staff felt was adequate to enable them to meet user needs, staff’ reported that there are always enough staff on duty even at meal times, additional staff hours are provided two days per week to enable some users to be taken out into the town. We consulted with staff on duty that told us that they have all received and completed mandatory training updates, all had achieved an NVQ2 or NVQ3 qualification and had been in post for more than two years. Staff felt confident any training issues they highlighted would be addressed by the manager or company, they feel well supported, find communication good and that a good sense of team exist continuity within the staff team aids this. Staff told us that Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 22 they feel listened to and able to influence service development. Staff demonstrated a good awareness of individual user needs and practised patience in working with individuals using a mix of coaxing and prompting, dialogue with residents was discreet when necessary respecting the discussion of personal care matters, staff demonstrated kindness, a positive attitude to the work they do and in most cases put into practice what they have learned, although some further thought needs to be given to moving and handling practice where this deviates from accepted good practice and this has been addressed elsewhere. The recent departure of two longer serving staff has brought a change in dynamic to the team with the appointment of two new staff, a review of their records confirms that the company operates a good recruitment process that ensures all necessary checks and vetting is undertaken prior to commencement of employment, references are taken up and in some instances additional references sought. The content of staff personnel files is mostly in keeping with the schedule, however, the lack of interview records means that the home cannot evidence that gaps in employment histories and reasons for leaving previous caring roles are adequately explored, improved photographs of staff should also be provided for the purpose of accurate identification. These areas have been discussed at the site visit with the manager who confirmed that exploration of prospective staff backgrounds is routinely undertaken at interview but not documented, she agreed that this is an area for improvement and it is therefore recommended that interview notes are formalised into the recruitment process. We noted probationary supervision reports on file and that new staff are undertaking completion of an induction workbook incorporating common induction standards. We noted that individual training records are maintained for each staff member with the company head office monitoring staff training updates. Staff told us that they have access to regular staff meetings and have supervision a minimum of eight weekly with either the deputy or manager, although either could be approached at any time. Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 23 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users live in a mainly safe and well-managed home that takes account of their best interests. EVIDENCE: At the site visit we spoke with the manager about the Annual quality assurance assessment (AQAA) information provided by the service to inform the inspection, although clear this was lacking detail in some areas and made no reference to outstanding requirements or what actions had been taken to address these, improvements to the way in which future information is provided and in what detail has been discussed and agreed with the manager. Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 24 We observed throughout our visit that the manager and staff ensure the home is run in the best interests of the service users, Staff we spoke with reported that they find the manager and deputy approachable and supportive, a relative also provided positive feedback about the manager and the home in general, expressing confidence in the approachability of the manager and her responsiveness to matters raised. AQAA information indicates that some policies and procedures may not been reviewed for more than two years, there being a lack of clarity as to whether the dates provided are for when documentation is looked at but not changed or the date when any change is made, the manager has been asked to seek confirmation from the company as to the frequency of policy reviews. It is clear from discussions with the manager and care staff’ that the company is proactive in ensuring staff have access to training where changes to legislation impact on the work of care staff and support of service users. The Home has taken action to address all previous outstanding requirements. The Company has a comprehensive quality audit programme, the manager confirms that regulation 26 visits are being undertaken regularly and copies of the last three visits have been requested as supporting information. The manager reports that User meetings have been held previously but are not effective in finding out from service users what they want and any concerns they may have, this is best handled through 1-1 sessions. Very few people within the home retain the capacity to speak in a group setting about things that they would like to improve, or change. Stakeholder surveys are carried out by the company and analysis of these and other quality assurance findings incorporated into an annual report, a summary of quality audit findings gave little information as to how stakeholder feedback has influenced service development and consideration should be given as to how this can be more clearly evidenced in future. Service users money is not managed by the home and no cash sums are held, families or representatives are invoiced for any expenditure made on service users behalf. Accidents records evidenced that a low level of accidents are occurring within the home, the manager attributes this to the fact that staff are not out of sight of service users in a staff room and are present within all areas of the home. An examination of the fire log has been reported on elsewhere in the report but indicates that fire arrangements are generally satisfactory. The Manager has indicated within AQAA information that all Health & Safety checks and servicing of equipment and services has been undertaken within last 12 months and a sample of servicing for the hoist and Parker bath were examined indicating servicing is occurring on a 6 month cycle. Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 25 Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 26 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 X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 4 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 3 3 3 X 2 X 2 STAFFING Standard No Score 27 3 28 2 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 3 Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 27 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 OP26 Regulation 16 (j)(K) 23(k) Requirement The provider shall ensure that: The frequency of carpet and floor cleansing is reviewed and increased in those areas identified as having heavy soiling or noticeable odour. That the emptying and cleansing of commodes is confined to designated bathrooms and that robust cleaning schedules are in place for these areas to minimise cross infection Timescale for action 15/09/08 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 OP8 Good Practice Recommendations The moving and handling support provided to service users by staff should for the purposes of maintaining health and safety always comply with current best practice and in accordance with an agreed moving and handling assessment of the individual concerned Administration of prescribed external medications must be DS0000021149.V368615.R01.S.doc Version 5.2 Page 28 2 OP9 Kilncroft Care Home 3 OP16 4 OP29 recorded onto medication record sheets. Codes used by staff on medication record sheets must have their meaning made clear if this different to preprinted codes already in use. A system should be developed that captures and records comments made by users about aspects of the service they receive where this may indicate a level of concern or distress by them and the actions taken by the home as a consequence Interview records should be available that evidence that employment histories and verification of reasons for leaving previous care roles has been fully explored with applicants. Staff recruitment files would benefit from improved photographs of staff to aid identification Kilncroft Care Home DS0000021149.V368615.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection CSCI South East The Oast, Hermitage Court Hermitage Lane Maidstone Kent 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. 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