CARE HOMES FOR OLDER PEOPLE
Kilncroft 25-29 Ashburnham Road Clive Vale Hastings East Sussex TN35 5JN Lead Inspector
Jeanette Denereaz Unannounced Inspection 5th October 2005 09:30 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 DS0000021149.V249200.R01.S.doc Version 5.0 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 DS0000021149.V249200.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Kilncroft Address 25-29 Ashburnham Road Clive Vale Hastings East Sussex TN35 5JN 01424 434921 01424 435893 kimcroft@craegmoor.co.uk 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) Parkcare Homes (No. 2) Limited Mrs Valerie Riedel Care Home 15 Category(ies) of Dementia (15) registration, with number of places Kilncroft DS0000021149.V249200.R01.S.doc Version 5.0 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 aged sixty-five (65) years or over on admission Service users with a dementia type illness only to be accommodated Date of last inspection 4th May 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 and there is a lift. 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 DS0000021149.V249200.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second in the year running from April 1st 2005 to March 31st 2006. The inspection took place between 9.30 and 13.00. The overall focus of the inspection was on meeting with the manager and reviewing the progress of the requirements from the previous inspection. A full tour of the home was undertaken. Time was spent meeting the manager, inspecting a number of records, policies, procedures and other documentation. Some resident and staff on duty were spoken to during this visit As this report was made following the second unannounced visit, and does not cover all the standards, therefore for the reader to make a judgment about the home, it is recommended that a copy of the last inspection report of the 4th May 2005 also be obtained to have a clearer picture of the home. What the service does well: What has improved since the last inspection?
The windows in the annexe have now been replaced. The Health and Safety documentation was found to be in order, unfortunately the maintenance person has now left, but in the meantime the manager is undertaking all the safety checks. The communal areas have been rearranged and the staff do encourage the residents to use all the areas, and a few have been spending time in the front lounge and the small quiet room. Since the last inspection the registered manager has successfully completed her Registered Manager’s Award (RMA). Kilncroft DS0000021149.V249200.R01.S.doc Version 5.0 Page 6 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. Kilncroft DS0000021149.V249200.R01.S.doc Version 5.0 Page 7 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 DS0000021149.V249200.R01.S.doc Version 5.0 Page 8 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 the following standard(s): All these standards were assessed at the last inspection, and were found to be met. Standard 6 is not applicable to this home. EVIDENCE: Kilncroft DS0000021149.V249200.R01.S.doc Version 5.0 Page 9 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 the following standard(s): All these standards were assessed at the last inspection, and were found to be met. EVIDENCE: As part of this inspection care plans were seen and found to be in order. Kilncroft DS0000021149.V249200.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 14 Residents are helped by the staff to exercise choice and have control over their lives in accordance with their individual care plans. EVIDENCE: The manager and staff have encouraged the residents to use all the communal areas, providing a quiet restful area away from the music and dining room in the front lounge. At the last inspection a resident expressed his dissatisfaction with living at Kilncroft, he felt it was not a suitable home for him, the registered manager agreed, and with the support of his care manager he has now moved on. Many activities are offered to residents, and the staff now record if there is a refusal to take part, or if an activity is successful and enjoyed by the resident. Kilncroft DS0000021149.V249200.R01.S.doc Version 5.0 Page 11 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 the following standard(s): All these standards were assessed at the last inspection, and were found to be met EVIDENCE: Since the last inspection there have been no recorded complaints from residents, their families, or other professional. Training in this area continues for all staff. Kilncroft DS0000021149.V249200.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 21,22 & 25 The residents live in a clean, warm and homely environment. However, many residents physical and health needs are changing, the home must provide were possible the facilities to ensure the residents are safe. EVIDENCE: The home is very homely and clean, there are adequate numbers of bathrooms on each floor and some rooms have en-suite facilities. However, the physical and health needs of the residents are changing as they become frail. Many residents use the only specialised bathroom in the home, with other bathrooms not used. It is recommended that the home review the bathing assessment of all residents, to ascertain if more specialised baths are needed within the home. Kilncroft DS0000021149.V249200.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 Residents continue to be supported by a well-qualified and motivated manager and a stable staff team who are well trained and supervised. EVIDENCE: It was evident during this inspection that the staff team are very respectful to the residents, the home has an unhurried routine and staff are prompt in meeting all the resident needs. Training is very important to the manager and the staff, and during this unannounced inspection the manager was undertaking health and safety training with staff. There is training planned throughout the year for staff in all the mandatory areas, and the majority of staff continue to work towards NVQs. Kilncroft DS0000021149.V249200.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33 & 36 The residents continue to benefit from a well-qualified and motivated manager and stable staff team. EVIDENCE: The Craegmoor organisation has introduced a formal supervision programme for all staff, which clearly stated achievements and areas for improvement in working practices for each staff member. Both the manager and deputy manager have been trained how to use the new supervision format. The supervision will take place six times per year and feedback from staff so far has been positive. It is evident during this inspection that staff have empathy for the residents, and are very respectful, understanding that this is the residents’ home. The manager is very motivated and has a ‘hands on’ approach to her role as the registered manager. She has recently successfully completed her RMA. Kilncroft DS0000021149.V249200.R01.S.doc Version 5.0 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. 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x x x 3 2 x x 3 x STAFFING Standard No Score 27 x 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 3 x x 3 x x Kilncroft DS0000021149.V249200.R01.S.doc Version 5.0 Page 16 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. Standard Regulation Requirement Timescale for action 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 OP22 Good Practice Recommendations It is recommended that the registered manager assess the bathing requirements of the residents and provided the appropriate bathing facilities to meet their needs. Kilncroft DS0000021149.V249200.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection East Sussex Area Office 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 DS0000021149.V249200.R01.S.doc Version 5.0 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. 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!
