Inspection on 16/04/08 for Kilpeacon House

This inspection was carried out on 16th April 2008.

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

Kilpeacon House 26/04/07

Kilpeacon House 16/06/06

Kilpeacon House 11/01/06

Kilpeacon House 19/07/05

Kilpeacon House 17/01/05

Kilpeacon House 21/06/04

Kilpeacon House 17/01/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Kilpeacon House Grey Road Altrincham Cheshire WA14 4BU Lead Inspector Sylvia Brown Unannounced Inspection 16th April 2008 11:00 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 Kilpeacon House DS0000005618.V362571.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. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kilpeacon House Address Grey Road Altrincham Cheshire WA14 4BU 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) 0161 928 2784 0161 929 6400 Mr James Skeath Mrs Lina Margaret Skeath Mrs Dianne Joan Chapman Care Home 24 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users will be aged 65 or over. Service users will require care by reason of either old age or dementia and may in addition have a physical disability. 26th April 2007 Date of last inspection Brief Description of the Service: Kilpeacon is a care home providing personal care and accommodation for 24 older people. It is owned by Mr. and Mrs. Skeath. The home is located in an established residential area of Altrincham, close to shops, bus and train routes and other amenities. The home is a detached twostorey building and has 14 single and 5 shared bedrooms, most of which have en-suite facilities. There is a dining room, a lounge with dining area, and a conservatory. A passenger lift is available. The home has parking spaces and well maintained gardens within the grounds. The current fees for the home range from £450 to £ 475 per week, with additional charges for hairdressing, personal toiletries, newspapers and magazines. Further information about the service is included in the home’s Statement of Purpose and Service Users’ Guide. These are provided to people living at, or considering a move to, Kilpeacon and are available to read at the home on request. Kilpeacon House DS0000005618.V362571.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 1 star. This means the people who use this service would experience adequate quality outcomes. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the last key inspection, which was completed on the 26th April 2007. We found the service to have positive outcomes for most service users, however systems and record keeping need to be developed to ensure that standards are appropriately maintained and to assist the registered provider and manager to demonstrate how they fully ensure service users health and safety. This visit was unannounced, the registered manager and staff were not told that we would be visiting. The registered manager was on duty throughout the site visit. We gathered information from a number of people, which included talking with and seeking the views of service users. We sent out surveys to service users, relatives and members of staff. This gave them an opportunity to talk with us about their opinions on the services provided at Kilpeacon House. Comments received are, where appropriate included within the report. In March 2008 the registered manager of Kilpeacon House completed a selfassessment form, which is called an Annual Quality Assessment Audit (AQAA). This told us what the home had been doing since the last key inspection to meet and maintain the National Minimum Standards. It also told us what they felt they were doing well, how they had improved within the past 12 months and their plans to develop in the next 12 months. We also gathered information through general contact with the home; through their reporting procedures, which are called ‘Notifications’, and through information we received from other people, such as the general public, including concerns and complaints procedures. There have been no complaints brought to our attention by service users or the general public. We looked in depth at records and the care support of two people living at the home. We also spent time sitting with service users and observing their dayto-day routines as they received service user or from care staff. This helped us get a better view about how people living at home are looked after and supported. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 6 From the information gathered we made the judgment about how the home was meeting the National Minimum Standards (NMS) and we made the overall judgement on the quality of the service. What the service does well: What has improved since the last inspection? The home has completed a fire risk assessment, which means that they are aware of areas of risk in the event of a fire and have a procedure for action should a fire emergency occur. Parts of the home have been redecorated and carpeted, so that the look of the environment has improved. The registered manager told us that they have improved the pre admission procedure, and that life profiles have been introduced, which will inform staff about service users past interests and hobbies. We have been told that this information will be used to develop a more varied activities programme for service users. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 7 Security has also been improved, which means service users are kept safer and the risk of service users leaving the home undetected has been reduced. The front external door has an electronic lock that is code activated and in the event of a fire emergency releases itself, enabling an unobstructed way out from the building. Night checks are routinely completed which includes checking of exits and windows. What they could do better: After observing medication administration, we think that action should be taken to make sure staff are trained and competent to administer medication. Staff should not handle medication and stringent hygiene practices should be in place if for any reason medication must be handled. Service users should be encouraged to take their own medication and or pots and spoons are made available to support them. Fire safety has to be improved. Bedroom doors should be monitored to make sure they close easily into their rebates, this minimises the risk of smoke inhalation and or spread of fire in the event of a fire emergency. The registered manager also needs to make sure all staff are to be trained and competent in the action to take in the event of a fire emergency. The manner in which the home records the daily life and care support of service users needs further development. Daily records should contain enough detail, to identify service users individual achievements, daily routines and activities. The registered manager should also develop practice that ensures differences is recognised, particularly where it relates to diversity and cultural heritage, and where ever possible meet service users request to meet with others from the same ethnic background. The home continues to require upgrading to ensure the comfort and safety of service users. Call points should have cords attached, which should be in easy reach for service users, to make sure they cam summon assistance when required. The quality of lighting should be improved to support those with failing eyesight and to provide a lighter environment. Service users would benefit from side tables, fixtures, fitting and soft furnishings. Consideration should also be given to the colours of walls and paintwork and appropriate signs could be in place to support those with failing mental health to find their way about the home. Social activities could be developed to ensure they are suitable for those with dementia and or associated conditions. We think that service users should be consulted more about their personal preferences for care and socialisation, and that after that has been done, the home should develop activities to suit individuals and the group. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 8 Individual personal care routines could also be improved, especially hair care for service users. Each person should be supported individually. Meals and mealtimes could be developed to make sure they promote service users independence and enjoyment. Consideration is needed to be given to the setting of tables and presentation of the dining area. We also think that the manager should be supernumerary to the care rota, to enable her to develop the home and ensure standards are maintained. We have made recommendations about paid training for staff and the introduction of induction procedures for new staff, which meet the standards, set by Skills for Care. We have also required that robust recruitment and selection procedures are put into place and followed to ensure service users safety. 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. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 9 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 Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 10 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. Standard 6 is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have their needs assessed prior to making any decisions about moving into the home and to ensure service users receive the support they require these assessments are kept under review. EVIDENCE: All prospective service users are able to visit the home and observed the dayto-day routines before they make any decisions about moving in. The records of two of the most recent admissions were looked at during this site visit. Prior to moving the service users had had their needs assessed by the placing authority. Furthermore, a member from the homes management team had visited them in their current placement and or home and completed their own assessment. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 11 Eight of the nine completed surveys from service users told us they received enough information about the home prior to moving in, which enabled them to make an informed decision about living at Kilpeacon. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 12 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each service users has their health care needs met, however medication administration practices places service users at risk from cross infection. EVIDENCE: The homes AQAA stated that since the last inspection considerable work has been done to improve the standard of detail within the care plans. Of the two care plans inspected both contained the correct information. However, more detail about service users personal preferences and preferred way they wish to receive support would ensure that the individuals’ needs were recognised and made know to care staff. In order to ensure that service users and staff can monitor personal belongings and identify when items are missing and or lost, each service users should have their own personal possessions list in place. These lists should details all their belongings including clothing and bedroom fixtures and fittings, together with items such as jewellery and ornaments. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 13 Health care checks were in place, with service users have access to medical health care professionals and check ups when required. The registered manager told us she recognised that records about service users daily life within the home need developing. We found that they were not sufficiently detailed to inform the reader about the routines of the individual and their achievements. Some staff use routine statements and/or failed to record any differences in the service users routines. Records should reflect what support service users have received to maintain their independence and how they have managed or not, to do things for themselves. Currently information about service users activities, night care and daily life are kept separately. Advice and recommendations have been given to developing recordings to reflect what happens each day and keep those records together; this would enable the reader to assess the service users behaviour and or routines and daily life as a whole rather in segments. Service users had their health care needs met, by visiting health care professionals. When asked about the support they received they told us “we are well cared for” and “the staff are very good.” Observations of one lunchtime medication administration process identified that staff were not following guidelines or administering medication in a safe manner. The administrator was observed to be wearing gloves, however then preceded to handle all medications including inserting it by hand into service users mouths. There was no hand washing completed between administrations, gloves were not changed and or hand gels used. Furthermore there was only a minimal amount of juice/water prepared. There were no medication pots evident and there was no attempt to use a spoon or encourage the service user to hold their own medication whilst they were taking it. This means that service users were places at risk through cross infection and had their independence was minimised. When asked the registered manager confirmed that those staff with responsibility for administering medication had received appropriate and up to date training. The home does not have a system in place for ensuring staff practice is monitored and that they are confirmed as competent to administer medication. When talking with service users, they gave us positive feedback about the home. They confirmed that staff listened to what they said and attended to their needs appropriately. Despite this it was observed that the care and attention to details was not always paid to service users hair. One service user was observed to be having their hair brushed in a lounge when preparing to go Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 14 to lunch. Furthermore the staff then proceeded to put the comb in their own pocket, indicating it was for general use rather than the service users own. A number of ladies had the same hair style, in that it was brushed straight down or back. It was explained to one family that the hairdresser had not been in attendance and appointments had been delayed. Many service users appeared to need their hair washing and styling. Those service users, who were more able to speak and communicate well, had received better support. This practice indicates that staff are not always aware of the need to support all service users in the same manner, which ensures their dignity and respect, regardless of the service users ability to understand and or communicate. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have some opportunity to join in social activities, however such activities need developing to make sure they are appropriate and meet the needs of all service users including those with dementia. The registered manager has yet to fully recognise the importance of identifying service users cultural diversity needs. Which means that service users are at risk of losing their identity and cultural heritage. EVIDENCE: The AQAA stated that the registered manager recognised “that all clients have different levels of capacity” and that their “ social needs may vary”. Because of this the home provides activities for service users. When asked about activities service users told us there were usually enough activities, but there appeared to be little enthusiasm about what was provided. During the inspection one service user was observed having one to one time with a member of staff, which assisted the service user to be calmer and less agitated. The home has not been trained in supporting people with dementia or mental health associated conditions. There was no information about what Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 16 activities were planned for each day and it was unclear is advice had been sought on the most appropriate activities for those with failing mental health conditions. In order to ensure that activities can be tailored to suit the needs of individuals, social assessments should be in place that identifies past, hobbies and interests, preferences then and now, remaining abilities and skills and a full assessment of their senses. When asked how the home could improve one relative told us “ possibly more entertainment.” could be provided. The registered manager recognised that external activities could be developed in order to ensure service users have the opportunity for social interaction both within and outside of the home. One service user was not of English birth and although living in England for most of their life, still had a strong identity with their heritage. Records detailed that the service user had requested to go to a “ club” where others from a similar background met, and to go to a Cafe where they served their favoured food from childhood. When asked how these request had been met, or if such foods had been purchased by the home, the manager appeared to have taken her lead from the service users family in that “ they had not had such food at home for years”. It is vital that the managers primary focus remains on the service user, and unless request are dangerous and place the service user and or others at risk, all their request should be recognised and validate and at least explored with the intent of where possible meeting service users request. We have been told that the menus have been developed to include a wider variety of food choices and service users preferred meals. Both the manager and staff confirmed that service users had been consulted about their favourite meals and what they would like. Inspection of the menu identified that breakfasts were not recorded and it was not know if service users had a choice or variety of any hot food options at breakfast. The recording system for noting service users intake was not correct, in that they did not specifically record all food taken. The record of meals served were collective rather than individual and they did not include, breakfast, suppers, food supplements, nutritious snacks and treats. More often than not the records detailed all service users has having the same meals. There was a menu board on display, however it was not of a sufficient size to attract service users and the writing to small for those with poor or failing eyesight. People with diminishing mental health need additional encouragement to eat and sustain a suitable diet; therefore such items as decorative notice boards and displays can for some encourage stimulation in the activity of eating. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 17 As stated previously daily records were not in detail therefore it could not be ascertained if service users were encouraged to rise and retire when they wanted. Mealtimes were set and in the main all service users sat together at mealtimes, which indicated that routines were based around staffs, practice rather than being service user led. However further observations would need to be made to fully validate this. Advice is given to the registered manager to review routines to ensure they are service user led. Observations of the lunchtime meal identified that little thought or preparation had been given to making the environment inviting. Tables although laid with a tablecloth, and cutlery, did not contain condiments, sugar bowls, milk jugs and or glasses and cups and saucers. Staff served juice collectively without asking service users if they would prefer one flavour to another. Hot tea and coffee was not offered at the mealtime. Staff continually handled drinks by the rim of the glass or cup and gave no thought to maintaining hygiene standards. Meals came ready plated, when asked service users did not know what was to be served and there appeared no system to inform them until in was placed in front of them. The registered manager has yet to develop service users meetings and or fully engage them in consultation, to routinely find out their views on the service, and how it could be improved. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and visitors have confidence that their complaints will be dealt with appropriately. We cannot confirm that all staff have received appropriate training in safeguarding vulnerable adults, which may place service users at risk. EVIDENCE: From the surveys returned, we able to ascertain that service users and visitors have been provided with information about the homes complaint procedures and that they feel able to use it when required. Eight of the nine service users surveys returned told us they knew how to complain and when asked if they were able to talk to anyone about their concerns, seven stated they always had someone to talk to, with another two stating they usually had someone to speak to. The AQAA stated all staff had received training in the protection of vulnerable adults and safeguarding procedures, and that the manager had completed alerter training. Records looked at confirmed that the behaviour of one-service users was causing concern and that some service users have been placed in a vulnerable position. Whilst the home has taken action to report this to the placing authority, it failed to notify us under regulation 37 which meant we did not know about it and the actions being taken to find an alternative placement for the service user. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 19 Notwithstanding the above information, service users and families have confidence in the manager and staff to act in the service users best interest. When staff were asked what would they do if any concerns were raised and or noted by them, one member of staff told us “I would advise the complainant to talk to the manager, we are trained by her to point out the complaints procedure which is in the hallway and gives the name and contact details of the CSCI and Trafford. Should they not be happy what we do with a complaint” another said “ I would report any major complaints or concerns to my manager, who will then be able to assess the situation and act accordingly.” Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 20 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): 19,20,22,23,24,25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was evidences that parts of the home had been partially decorated and carpeted, however to ensure the needs, comfort and safety of service users is met, further upgrading is required. EVIDENCE: Since the previous inspection parts of the home have been redecorated and recarpeted. However the colour scheme used, does not promote a sense of well being for those with mental health or dementia related conditions. Such people benefit from light airy surroundings with tactile surfaces and orientation aides to enable them to find their way around their surroundings and to know which room they are in. Walls were mostly painted cream and dark carpeting coupled with dark doors and insufficient ighting, was and is not the best colour scheme for promoting best mental heath and a sense of well being. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 21 The lay out of the main lounge is poor and service users do not have the opportunity of using side tables. The rooms lack soft furnishing. A number of service users cannot see the television form their seats and music played in the adjacent seating area can be heard along with the television. During the inspection time was spent sitting in this area with service users. They were observed placing hot drinks on the floor, culminating in them bending down to get them or forgetting drinks were there. Some service users were observed trying to hold their cup and saucer on their knees. This places service users at increased risk of injury. Some service users were observed sitting for considerable time in chairs that had no additional cushions or footstools, which may offer additional comfort and support. One lounge has minimal natural light and service users have to sit in a room with poor artificial lighting. This is not good for those with failing eyesight and does not encourage a sense of well being. The conservatory area does however offer service users a light and cheery place to sit and relax. A sample of bedrooms were looked at. All were clean and tidy and reflected service users individuality, however lighting was poor in parts. Most rooms did not have wallpaper and appeared uniform in colour. One service users room had walls that were marked. Some call points did not have appropriate cords and one service user was sat in a room but could not summon assistance if required. Not all bedroom doors had numbers and some has sticky labels to indicate who the service users were, others just had torn labels evident. There was no evidence that visual aids are used in the home to assist service users to find their way to their own rooms and or identify various areas within the home. Not all bedroom doors had appropriate locks, which meant that access could be gained to rooms in the absence of the service user. Whilst it was noted within the homes response to a complaint, that it did not want to become institutionalised in its appearance, best practice is to have clearly identified areas by the use of colour and signs to support service users who have failing mental health conditions. Some bedroom doors did not appear to close appropriately into their rebates, which in the event of a fire emergency could place service users at risk of smoke inhalations and increase the spread of fire. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive support from staff they know and trust. Robust recruitment procedures are not in place and or always followed, which may place service users at an increase risk of harm. EVIDENCE: Although the staffing levels appeared to be sufficient on the day of the site visit, the rota does not accurately reflect the actual hours for care. In that care staff also complete cooking duties after 2pm. Domestic and cooking hours are not recorded and staff’s full names and positions were not noted. The rota also identified that some staff are routinely completing shifts of fourteen hours, which is not best practice and not advisable in the caring profession, it does not ensure and or promote staff to be alert and motivated, which may culminate in service users receiving inconsistent care support. When asked about staffing levels, staff told us that they felt staffing levels should be increased when service users dependency increased and or sickness was evident within the home The home manages to retain staff and continues to have a low turn over of staff. The registered manager told us that 98 of the staff team have Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 23 completed NVQ training at level 2 or above, which exceeds our minimum standard. The AQAA stated the home operated a robust recruitment and selection procedure, however through inspection of records and from discussions with the registered manager, it has been identified that the registered manager must review recruitment and amend procedures to ensure that they include prospective staff completing their application prior to being interviewed. That they attend a face-to-face interview and that procedures include formal offers of appointments and clear probationary periods. Contracts of employment should also be in place. The home must operate robust recruitment procedures at all time for the safety of service users. Inspection of two of the newest staff identified that application forms were basic in their content but included all the required elements. A reference for one person was dated the same day as the application was completed. It was found that this person had been interviewed prior to completing an application, and once completed also included a written reference. The registered manager stated that she always rings referees to confirm they have supplied the reference, which is good practice, however the order in which information is obtained is incorrect. It is also advisable to record telephone confirmations and discussions held with referees. Both files did not contain a current photograph of the staff. Letters of appointments were not in place, probationary periods unclear and what was to be achieved. The home completed its own induction, which appeared to be of a good standard, however the home has yet to implement induction procedures issued by Skills for Care, which supports continuing professional development, including helping prepare workers for entry onto the appropriate Health and Social Care National Vocational Qualification (NVQ). Staff have statutory checks made, however the home appears to routinely start staff on receipt of POVA first checks. The registered provider stated that their continues to be difficulties in obtaining full CRB check in a timely manner due from the statutory bodies. Notwithstanding this information we informed the registered provider and manager that this is not best practice and should only be implemented if there is a staffing crisis. Employers should wait until they have received a full-enhanced disclosure before enabling employment to commence. Where prospective employees state they have qualifications, they should produce certificates, and where the home relies on them to confirm staff are trained, copies should be retained on file. This was not practiced within the files looked at. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 24 Staff sign records to say they have had access to the staff hand book, however best practice would be to ensure that they receive their own copy for reference purposes. There was evidence that staff received the General Social Care Councils, Codes of Conduct. The registered manager permits school age young people to complete work experience within the home. There were no records maintained as the young persons suitability and or reasons for wanting the experience. There were no indicators that they had been informed about codes of practice and conduct. There was nothing to confirm that the young persona had received guidance about areas of support they are able and not able to complete. There was no mentoring system in place and or an identified person who was overseeing and supporting the young person. Staff told us that they received training and regular update, however one told us that unless they are on shift they do not get paid to attend training. Best practice would be to where ever possible, provide training when staff are not on shift, this ensures that training events to not affect service delivery to service users. Furthermore it enables staff to concentrate solely on the training being provided. It is expected that all staff within the home receive up to three days paid training per year, which should ensure their attendance. Staff spoke positively about the staff team; with one person saying “the staff are very good” Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 25 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, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is trained and competent and with limited management time tries to manage the home in the best interests of service users. EVIDENCE: The registered manager has stated that it is her intention to encourage an open friendly environment at Kilpeacon, which enables services, visitors and staff to share their views and contribute to the development of the service. She has worked for the providers for over 14 years and has the appropriate skills and training to manage a care home. The inspection has identified a number of areas where it needs further development. In discussion with the manager it became apparent that she is Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 26 not always supernumerary to the working rota and is included as part of the direct care support team. The difficulty of managing a care home, whilst also working on the care rota was discussed and it is recommended that this is reviewed with the aim of the manager being completely supernumerary to the rota, to enable her to develop the home where required. The home has yet to develop formal routine consultation meetings with service users and relative, which encourages them to influence care service provision. The registered manager stated that she would be developing this area of practice in the future. The home has completed a quality assurance audit and produced a public report of the outcome. It is unclear how this has been published within the home and or provided to service users Inspection of health and safety records identified that servicing records were up to date and maintained, as was insurance and servicing contracts. Fire safety records did not confirm that all staff including night staff had completed a practical fire drill within the last six months as recommended by the fire safety service. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 27 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 X 2 X 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 28 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 OP9 Regulation 13(2) Requirement The registered manager must ensure that all staff with responsibility for medication administration administers medication in a safe and appropriate manner at all times. Service users must have easy access to summon assistance at all times, particularly when seated in their bedrooms. Timescale for action 20/04/08 2 OP22 16 .2 (c) & 23.2 (n) 19 30/04/08 3 OP29 4 OP38 23.4 5 OP38 23.4 (e) The registered manager must 30/04/08 develop a robust recruitment and selection procedures, which are followed at all times. To ensure service users safety, 30/04/08 and be compliant with fire safety regulations, the registered manager must ensure all bedroom doors close smoothly and correctly into their rebates. To ensure all staff are trained 30/04/08 and competent, staff training in fire safety, which includes practical fire drills, should not exceed six months. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 29 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 2 3 4 Refer to Standard OP7 OP12 OP7 OP9 OP10 Good Practice Recommendations Daily records should reflect their daily life within the home, this achievements and individuality as well as cares staffs’ individual support. Each service user should have an accurate and up to date personal possessions list, which includes clothing and fixtures, fittings and personal items. Systems should be in place to ensure that staffs practice is monitored, particularly medication administration, and that they are competent to carry out such duties correctly. The individual needs of service users should be recorded in sufficient detail as to identify their personal preferences for care and their care needs, particularly where that relates to diversity of culture and ethnic background. Systems should be in place which ensures that service users receive the personal care and attention required at all times and which promotes dignity and respect of the individual, including support with hair washing and styling. The activities programme should be reviewed, to ensure that it is suitable to meet the individual and group needs of all service users including those with dementia and or associated conditions. Specialist advice should be sought about appropriate activities and training provided to ensure the social needs of service users with dementia and or associated conditions are met. The routine for meals and mealtimes should be reviewed, to make sure that such times are enjoyable events for service user. Attention to detail about place settings, the promotion of independence and improving choice should be practiced. The manager should ensure that the home is equipped with suitable aids and adaptations to support those with dementia and or associated conditions, including pictorial and large print menus, rooms signage and colours to assist in orientation. The manager should make sure systems for recording service users dietary intake are maintained accurately and include all meals, snacks and supplements taken. The registered manager should keep us informed as stated DS0000005618.V362571.R01.S.doc Version 5.2 Page 30 5 OP10 6 OP10 7 OP10 7 OP15 8 OP15 OP22 10 11 OP15 OP18 Kilpeacon House within regulation 37 of all significant incidents within the home, which adversely affects the well being and safety of service users. The manager must be familiar with all aspects of regulation 37 and her responsibility to notify us of any events listed. Arrangements should be made to ensure that service users have a view of the television when seated in the lounge areas and that radio and television sounds are not competing with each other, hampering service users enjoyment and increasing confusion. The registered manager should ensure that all rooms are suitable to offer service users comfort when seating and which promotes their safety, including the provision of appropriate lighting, cushions and side tables. A review of all rooms used by service users, particularly their bedrooms, to ensure they are decorated appropriately. Ensuring service users have been consulted about colour and decoration. The homes staffing rota should clearly detail the names and staffing positions of all staff. Those staff undertaking cooking duties should be clearly identified and the time spent on such duties. It should record the individual hours worked including those worked by ancillary staff. The registered manager should ensure that staff cease working excessively long shifts. The homes staffing rota should be kept under review to ensure that staffing numbers are adjusted at times of higher need, particularly when service users needs are increasing and or when they are sick. Systems need to be introduced to ensure that trainee and work experience staff have records to verify the registered manager has provided the appropriate induction, guidance, training and support, which safeguards them and service users. All staff should receive their own copy of the homes staffs’ handbook. All new staff should complete the Skills for Care induction training. All staff should receive three days paid training as per year as part of their employment. A review of the managers’ hours should be undertaken, giving due consideration to being of the care rota to complete her management responsibilities and develop the home. Systems should be introduced to routinely consult with DS0000005618.V362571.R01.S.doc Version 5.2 Page 31 12 OP22 13 OP22 14 OP24 15 OP27 16 17 OP27 OP27 18 OP27 18 20 21 22 OP27 OP30 OP30 OP31 23 OP33 Kilpeacon House service users to enable them to comment on service provision and influence how the home is developed. As stipulated within regulation 24. Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Kilpeacon House DS0000005618.V362571.R01.S.doc Version 5.2 Page 33 - 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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