Inspection on 04/05/05 for Kilncroft Care Home

This inspection was carried out on 4th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 11/09/07

Kilncroft Care Home 15/08/06

Kilncroft Care Home 05/10/05

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 25-29 Ashburnham Road Clive Vale, Hastings East Sussex TN35 5JN Lead Inspector Jeanette Denereaz Unannounced 4 May 2005 09:00 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 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 H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Kilncroft Address 25-29 Ashburnham Road Clive Vale Hastings East Sussex TN35 5JN 01424 434921 01424 435893 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Parkcare Homes (No. 2) Limited Craegmoor Healthcare Ltd. Mrs Valerie Riedel Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (OP) 15 of places Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of residents to be accommodated is fifteen Date of last inspection 18 January 2005 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 pre-senile 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. Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the first in the year running from April 1st 2005 to March 31st 2006. The inspection lasted from 9.00 until 14.30. Time was spent meeting with the manager and going through various records and documentation, a full tour of the home including an invite to join the residents and staff for lunch. Time was spent meeting with residents, in groups and individually, also the Inspector interviewed a visitor to the home. In the afternoon the Inspector attended the staff meeting. In this report the service users will be referred to as residents. 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 6 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 Standards Statutory Requirements Identified During the Inspection Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 & 5 Prospective residents, their care managers and families are given all the information they need to able to make an informed decision to live at Kilncroft. EVIDENCE: Since the last inspection there has been two new residents come to live at Kilncroft. They and their families were given a copy of the statement of purpose, and because of the special needs of the residents a life history is sort from family members if possible. The Inspector spoke to the residents, and they were both quite settled with comments of “It’s lovely here”, “The staff are very nice” and “The food is nice”. It was evident that the manager had carried out a detailed pre-admission assessment, families had visited the home before they relative took up residence. The families continue to visit regularly, and the staff and manager are getting to know them, which is seemingly very important to the manager that families feel able to visit and discuss their relative’s care. Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 & 11 Residents are treated with genuine respect and dignity by support staff. Individual health and social care needs are well supported. EVIDENCE: Sadly, a resident has recently died, and the family had written to the Manager and staff thanking them for the care, kindness and support given to their mother during her stay and at the end of her life. The residents’ needs are identified and documented within a comprehensive care planning system, and the manager is in the process of reviewing and all care plans to ensure that the changing care needs of residents are recorded. Medication was inspected and was found to meet all aspects of the standard in relation to storage, dispensing, training, and overall record keeping. Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 & 15 Residents are encourage to make choices as far as possible about all aspects of their daily lives, supported through a range of activities in the home and in the local community. EVIDENCE: Residents’ visitors were in the home during the inspection, and the Inspector spoke to one visitor. The visitor was a family friend, and he said the care was adequate, but his friend was a very private person and the lounge could be very noisy. This was observed by the Inspector, however, there is another lounge and quite room at the front of the home which rarely used. The manager discussed the new initiative of ‘Diversity therapy plans’ for each resident. The key workers will note in the plan if a certain activity interest the resident, and the examples given were if a resident enjoyed a certain food, place, tea shop, a song or piece of music, and even little things if the resident enjoyed tiding their wardrobe with a member of staff. The Inspector was invited to join the home for lunch, and the meal was found to be tasty and wholesome. Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 10 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home operates in an open and pro-active manner and complaints are handled properly. The majority of the staff team have received relevant training on protecting vulnerable adults from abuse. EVIDENCE: The home has detailed complaints policy and procedures. Since the last inspection there have been no complaints made. The manager has a good understanding of the implementation of Protection of Vulnerable Adults (POVA) register. A resident that was interviewed stated the ‘staff are polite and respectful’, the only concern was he wants to live in another home, and had the opportunity to discussed this with the manager and his social worker. Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,23,24 & 26 The residents live in clean, warm and homely environment. However, the back lounge can at times become noisy for some residents. EVIDENCE: The home is homely and clean and all bedrooms were inspected and were found to be in good order and some are personalised by the residents’ families. There are still building works to be completed, which have been outstanding from previous inspections, which include the replacement of windows. During this inspection most resident were in the back lounge nearest to the kitchen and dining room, and following the observation of this room becoming noisy a recommendation would be to encourage residents with staff support to use all the communal space within the home. Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 12 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Residents are supported by a motivate manager and stable staff team who undertake a range of tasks. EVIDENCE: There is a staff team of 20 in total with 3 support staff, and 1 senior on per shift. There are extra staff for cooking and maintenance. The inspector observed that the staff in unhurried routines was promptly meeting all residents’ needs. The home has an appropriate induction programme, which is undertaken by all new staff. The manager and deputy manager are qualified to teach Health and Safety and food hygiene. There is training planned throughout the year for staff in all the mandatory areas including the control of infection, and COSSH. The majority of the staff are undertaking NVQ training. The home has achieved the ‘Invested in People’ award. Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 13 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,34,35,37 & 38 The residents continue to benefit from a well-established and motivated manager, and stable staff team. The home was found to be conducted in an open and friendly manner with staff supported to carry out their roles. A concern was with the lack of information with recording and checking of Health and Safety areas, undertaken by the maintenance person. EVIDENCE: Since the last inspection the organisation Craegmoor have introduced a new computer programme called ‘Requisoft’ for all financial matters within the home. The manager maintains that this system offers a clear audit for the home’s accounts. The manager ran through the system with the inspector. The home now has a ‘clocking in system’ for staff and this information is given to the Head Office to calculate salaries. The record keeping within the home is generally of a good standard, however, there were gaps found in the recording of fire equipment checks and water temperatures. Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 14 The manager needs to urgently address these shortfalls in the Health and safety checking and supervisor the maintenance person to ensure the record keeping within the home is accurate and up to date. Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 15 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 2 x x 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x 3 x x 3 3 x 2 2 Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 16 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. Standard 19 Regulation 23(2)(b) Timescale for action It is required that windows in the 30/06/05 annexe been replaced. This is a requirement from the last four inspections. It is required that the registered Immediatel manager ensures that all y necessary Health & Safety checks are carried out regularly, and the person with this responsibility is supervised. Requirement 2. 38 13(3)(4) (6) 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 12 & 20 Good Practice Recommendations It is recommended that all communal space is available for residents, and they are encouraged to use the space when other areas become noisy. Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 17 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kilncroft H59-H10 S21149 Kilncroft V222527 040505 Stage 4.doc Version 1.20 Page 18 - 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. 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