Inspection on 13/05/08 for Kilvie House

This inspection was carried out on 13th May 2008.

CSCI found this care home to be providing an Good service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kilvie House 04/01/06

Kilvie House 06/07/05

Kilvie House 23/02/05

Kilvie House 03/06/04

Kilvie House 24/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Kilvie House 25 Downend Road Kingswood South Glos BS15 1RT Lead Inspector Sandra Jones Unannounced Inspection 13 & 16th May 2008 09:30 th Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 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 Kilvie House DS0000020246.V359236.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 Adults 18-65. 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. Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kilvie House Address 25 Downend Road Kingswood South Glos BS15 1RT 0117 3009885 NONE 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) admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Mr Peter Hayes Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate up to 8 Persons with learning disabilities who are receiving nursing care. Staffing Notice dated 07/09/2000 applies Manager must be a RN on parts 5 or 14 of the NMC register Date of last inspection 28th September 2006 Brief Description of the Service: Kilvie House is a Care Home operated by Aspects & Milestones Trust. The Home provides nursing care for a mixed resident group of up to eight adults with learning disabilities. A qualified nurse is on duty at all times. The home is set in a residential location in Kingswood, and is within walking distance of local shops and amenities. The home is a converted older property providing accommodation over two floors with lift access to the second floor. Bedroom accommodation is provided in eight single rooms. Communal areas include two lounges and a dining room, all of which are fully utilised. Bathrooms and toilets have been fitted with adaptations to meet the care needs of the service users in the home. There is appropriate provision of equipment to assist staff and residents. The Home is set within its own garden, and the main entrance is to the rear of the house. There is level access to the gardens and to the local shops. The Home has its own transport, which provides access to day care and social venues. The fee charged for residents to stay at the Home is £1455.29 a week. Kilvie House DS0000020246.V359236.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 star. This means the people who use this service experience good quality outcomes. This key inspection was conducted unannounced in over two days in May 2008 and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedures. During the site visit, the records were examined and feedback was sought from individuals and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection and this information was used to plan the inspection visit. “Have your say” surveys were sent to people who use the service, their relatives, staff and health care professionals. Surveys from one relative and three staff were received at the Commission. Kilvie House was involved in a thematic inspection and its purpose is to provide a national picture of the quality of services in a particular area. Our Inspecting for Better Lives action plan identifies themed inspections as one of the key ways to get information about the quality of specific aspects of social care services. This thematic inspection will focused on issues surrounding ‘safeguarding’ There are six individuals currently living at the home and four people were case tracked. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the people living at the home and staff were gathered through face-to-face discussions. What the service does well: Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 6 One person giving feedback made the following comments. “Members of staff knock on the door before they enter, personal care takes place with the door shut and the deputy manager would be approached with complaints.” These comments indicate that individuals are treated with dignity and respect and are confident that complaints would be taken seriously and acted upon. The relative that responded though the survey stated, “ They look after my brother well and try hard to improve his quality of life. The staff are not content just to look after him but constantly asses his needs and try to help him relate better to his surroundings. They have discovered things that we never new existed and they are supporting him with communication.” Through the survey a member of staff made the following comments about what the service does well. “Care for people, acknowledge the needs of people at the home and training.” What has improved since the last inspection? What they could do better: There are three requirements arising from this inspection and they are based on reviewing systems already in place. Moving and handling risk assessments for one specific individual must be reviewed to ensure that up to date lifting techniques are being used. Protocols for “when required” must be included into the individuals medical guidelines to ensure medications is consistently administered. Fire risk assessments must be reviewed to ensure that from the assessment preventative measures are taken to prevent an outbreak of fire. Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 7 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. Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (2) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. There is an effective admissions procedure in place, which supports individuals to make an informed choice about moving there. They can be reassured that the home will have the skills and resources to meet their assessed needs. EVIDENCE: The home has a Statement of Purpose, which the manager is currently reviewing to update the information contained. It states that the Service User Guide is available in other formats including pictures and symbols to ensure that the people for whom its intended can understand it. A talking book format is planned and will further ensure that people can make choices about living at the home. The response received from the relative through the “Have your Say” survey confirms that the home always provides enough information to help make decisions about the home. Assessments and admission procedure is described and makes it clear that all admissions are based on full assessments and describes the model used to assess the individuals suitability to live at the home. The deputy manager said the usually referrals are from the social worker through the organisation and Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 10 the first assessment is through the needs assessment provided. Visits are then conducted for a face-to-face assessment to determine if their needs can me met and introductory visits are arranged following from the visit. A meeting with the staff is convened following the visit to discuss the finding before the admission is confirmed. A care plan is developed from the information gathered. Two people were recently admitted to the home and their case files were examined to establish the procedures followed at the home. One person was admitted to hospital soon after their admission and a re-assessment will take place before this person returns to the home. A social workers needs assessment was provided for the other person and the manager is undertaking assessments to establish their suitability to live permanently at the home. Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (6), (7) & (9) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. There are effective care planning systems in place for individuals to benefit from receiving an individualised and consistent service. They can expect to be involved in making decisions about all aspects of their care. EVIDENCE: People at the home have a Care Plan Pack and Care Plan file. The register held within the individuals care plans lists personal information that includes next of kin, GP’s name and other contact details. There are Personal Care and Mental Capacity Act Care Plan Statements are developed for each pack persons and preferences regarding the gender of staff that provide intimate care, their routine and likes and dislikes which establish the person’s lifestyle is included in the Personal Care Statement. The Mental Capacity Act (MCA) Care Plan makes it clear that the people being supported have the right to be supported to make decisions over all aspects of their lives. Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 12 Care plans are sectioned into Maintaining a Safe Environment, Communication, Mobility, Eating and Drinking, along with Personal Care, Working and Leisure. They are written in the first person and include the individuals likes and preferred routines, for one person daily routines are more detailed and structured to meet their needs. For people with communication need, care plans describe the individuals preferred means of communication. For example, one person has a specific vocabulary and a glossary of the words is provided to ensure that this person can be understood and staff can empower this person to make decisions and other care plans in place specify the way individuals make choices. Members of staff have attended the MCA training and as a result of the training the MCA statements were developed and endorse that people living at the home have the right to make decisions about their lives. The deputy manager stated that people at the home have different levels of communication and staff use expressions of moods to establish their satisfaction with the tasks or activities taking place. Members of staff consulted during the inspection said that they had attended MCA training and explained that the assumption is that people can make decisions for themselves. Members of staff record daily activities, observations of the person, outcome of visits and tasks undertaken by the person. It is acknowledged that the staff team have very specific knowledge of the people living at the home because to the number of years staff have supported the individuals. Care plans and daily reports must be more detailed, in terms of the care plans information about likes and preferred routines must be more specific and daily reports must show the decisions made by the person. The deputy manager was consulted about the care planning process including the key worker system in operation. It was stated that senior staff regularly meet with keyworkers to discuss the person’s changing needs and where necessary amend the care plan. It was also stated that relatives and social workers are invited to review meetings. Two staff surveys were received and their comments reinforce that they are provided with up to date information about the needs of the people living at the home. Members of staff giving feedback were clear about their role as keyworked and gave the following examples of the responsibilities of the role. It was stated that on going shopping trips and developing a bond between the person and member of staff were responsibilities of the keyworker role. Through the survey a relative confirmed that the home always meets the needs of their relative living at the home. Risk assessments are in place for activities that may involve an element of risk and mobility, self-injury, eating and drinking risk assessments are in place. For one person the nature of the risk and preventative measures to reduce the Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 13 level of risk are described and for another a pictorial format is used to instruct staff on the correct equipment to be used. The risk assessment for one person must be reviewed to ensure correct up to date lifting techniques are used. Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (12), (13), (15), (16) & (17) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. There are good support systems in place for residents to lead active and interesting lifestyles and to be valued members of the community. EVIDENCE: Working and Leisure forms part of the care planning process and generally the people at the home participate in a wide range of in-house and community activities. For example, an Aromatherapist visits the home and, people at the home attend day care centres, Dance Voice and Hydrotherapy. Each person has an activity day care chart and members of staff record daily events and confirmed that individuals attend Dance Voice, go on outings and shopping trips. The deputy manager said that individual’s expression and body language are used to establish the person intention to participate. During Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 15 the inspection one person was having 1:1 day care from an outside agency to pursue an Arts and Craft hobbies. This shows that the staff at the home support people at the home to develop their hobbies. The manager and deputy manager said that the people at the home are recognised in the local community because they access local amenities. People at the home visit local pubs, shops and have contact with neighbours. The home has its own transport and one person also has a car wish the staff will eventually drive to provide transport. The home recognises the importance of supporting people to maintain links and relationships with family and friends. The policy states that relatives are welcome and where necessary individuals will be supported to visit family in their own home. The survey from a relative states that the home always supports their relative living at the home to keep in touch with them. A Privacy and Dignity policy that sets the approach for respecting people at the home is not currently appended onto the Statement of Purpose. The deputy manager explained the way individuals at the home are respected as individuals. Examples given include seeking consent from people before tasks are undertaken and opportunities to attend multidisciplinary meetings. One individual was consulted about the way their rights are respected and this person said that the staff knock before they enter bedrooms. Regarding the expectation that staff interact with people living at the home, the deputy manager said that individuals sit in areas where staff are working. For example, the dining room and kitchen are areas where people sit together and being aware that people that sit on their own need to be stimulated. A record of food provided is maintained and supports comments from staff that individuals are given a daily choice of meals to be served. The range of fresh, frozen and tinned foods confirm that people have a varied and nutritious diet. Generally a continental style breakfast, light lunch and cooked tea is served at the home. Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (18), (19) & (20) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Individuals can expect sensitive and prompt support for their personal and health care needs from a skilled staff team. Medication systems are safe. EVIDENCE: Personal Care Statements within the individual’s case records lists the individual’s preferences and daily routines. Times to rise and retire preferred appearance and mobility needs are also included within the statement. Personal care and continence needs form part of the care planning process and guide the staff on the actions to be taken to meet the assessed needs. Individual’s likes and preferences are also incorporated into their care plan. One person that has more specific needs, the daily routine plan is specific and guides the staff on meeting the needs. One person living at the home said that the assistance provided by the staff takes place in their en-suite with the door shut. Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 17 People at the home have mobility needs and the assistance needed with listed in their personal statements. Mobility needs are included in the care plan and for some individuals a pictorial format is used to show staff the best method of positioning, hoisting and use of equipment. People at the home have specialist support through the Community Learning Disability Team (CLDT). The input form outside professionals is listed within the individuals profile and records show that physiotherapists, speech and language therapists dietician are involved in the care of the person. Health action plans are included in the individuals care plan files. It states the individual’s health care needs, checks conducted by the staff to stay healthy and input from health care professionals. Guidance is available for staff to follow in the event of one person’s medial emergencies such as epileptic seizures and heart failure. A record of heath care checks is maintained and records show that monthly observations such as the monitoring of weight. Individuals visit the GP and access NHS facilities; appointments are regularly arranged to the dentist, chiropodist and optician. Members of staff consulted during the inspection said that they accompany individuals on health care appointments. Through the survey a relative stated that the home always keeps them informed about important issues. Medication guidelines about the way medication is to be administered along with the medications prescribed, their purpose an side effects. Within the guidelines protocols for “when required” medications are not currently included. The manager must include protocols to ensure medications are consistently administered. Correspondence from the CLDT and Primary Care Trust (PCT) include statements about the person’s ability to make decisions about medication. “Best interest” decisions about the way medications are to be administered to the person are described. Other “best interest” decisions about administering medication before health care appointments are described within their health action plan. Medications are administered through a monitored dosage systems and the records of administration corresponded with medications held. Records of administration show that staff use the correct use of codes for not administering medications and sign records immediately after administration. A record of medications no longer required is maintained and the pharmacist signs the records to indicate receipt for disposal. Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 18 Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (22) & (23) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Complaints procedure is included within the Statement of Purpose. Explained within the procedure are the reasons for the procedure and the steps that will be followed for investigating a complaint. The copies of the complaints procedure in individual’s bedrooms are in a pictorial format to ensure that the people for whom it’s intended can understand the procedure. There were no complaints received at the home and the Commission since the last inspection. The deputy manager was consulted about the way individuals are supported to raise concerns and complaints. The deputy manager said staff, parents and the network of people involved in the care of the person will advocate on behalf of the people at the home. The survey from the relative stated that it is unlikely that cause to complaint would arise. Members of staff stated through the survey that they know what to do if a person at the home, relative or advocate had concerns about the home. Aspects and Milestones have policies and procedures that endorse a commitment to safeguarding individuals form abuse. The Protection of Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 20 Vulnerable Adults procedure specifies the principles of abuse and the actions to be taken to safeguard individuals. The “Do the right thing” policy is not available at the home. The manager said that there are no outstanding Safeguarding Adults referrals. As previously mentioned within the body of this report, this home was part of a thematic inspection. Its purpose of is to provide a national picture of the quality of services in a particular area. Our Inspecting for Better Lives action plan identifies themed inspections as one of the key ways to get information about the quality of specific aspects of social care services. This thematic inspection will focused on issues surrounding ‘safeguarding’. Members of staff were clear about their responsibilities to safeguarding adults from abuse including reporting poor practice. The definitions of abuse and the actions to be taken were described and the actions to be taken follow “No Secrets” guidance. Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (24) & (30) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home is well maintained and individuals benefit from living in a comfortable and clean environment. EVIDENCE: Kilvie House is close to local shops and individuals can easily access local amenities. It is a converted residential style property in a quiet residential area. The people at the home moved out between 02/06/07 and 08/12/07 while work to extend the property took place. An office, laundry room and sluice, dining room and two en-suite bedrooms were created and en-suites were installed in four bedrooms during this period. The Home was clean, tidy and satisfactorily maintained in all areas viewed. It is arranged over two floors with communal space on the ground floor and Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 22 bedrooms on both floors. There is a lift for individuals that have mobility needs with accessing their bedrooms and communal space. The entrance of the building is to be rear and provides very easy access for wheelchair users. There is a dining room/ lounge and kitchen with a television, as well as a `quiet’ area with no television in. Individuals were observed sitting in the lounge and dining room, and looking relaxed and comfortable in their surroundings. Bedrooms are decorated and furnished to reflect the person’s interest and lifestyle. There were visual stimulation aids as well as relaxation aids including wall lights and mobiles to provide additional stimulation and relaxation. Bedrooms are decorated in different colours and this helps to create an individual feel to rooms. Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (34) & (35) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Individuals are supported by a competent, qualified and skilled staff team who are well supervised. EVIDENCE: The personnel records were recently transferred from the Trust office to the care home. The personnel files of the staff recently employed at the home were examined. Completed applications forms, two written references and notifications of Criminal Records Bureau (CRB) disclosures obtained are held within personal files. A member of staff recently employed explained that before starting work at the home applications forms had to be completed, references sought and CRB were obtained. The surveys from the staff confirm that checks were conducted before they started work at the home. Staff’s personal development was discussed with the manager who stated that training needs are discussed during individual supervision. Staff are able to attend training advertised or the manager would suggest training. Since the Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 24 last key inspection, the staff have attended Mental Capacity Act training. Qualified nurses attended gastrostomy training from the PEG suppliers. Support workers undertake vocational qualifications and the manager said that either have or are registered onto NVQ level 2. Qualified nurses also act as the home’s NVQ assessors and support care workers with the training. The relative said through the survey that members of staff always have the right skills and experience to look after people property. The following additional comments were made “ They are always cheerful and kind. The activities they do with my brother are brilliant.” The staff that responded through the survey stated that they have access to training that is relevant to their role. Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (37), (39) & (42) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Individuals can expect to live in a safe environment and can be re-assured that standards will be the subject of ongoing monitoring. EVIDENCE: The registered manager is a qualified nurse and has almost completed RMA. The manager went on to explain that encouraging staff, having good clinical knowledge and being client centred are the style of management used at the home. Consistency of care was also discussed and the manager said that being a “hands on” manager, holding meetings to discuss issues with staff and individual supervision were systems used to maintain consistency of care. Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 26 Members of staff were consulted about the style of management and stated that the manager is a role model and is approachable. Regarding systems that ensure consistency of care members of staff confirmed that supervision and staff meetings occur regularly and handovers take place during shift changes. These comments confirm that staff have enough information to meet the individuals changing needs. The rotas in place are to meet the needs of up to eight people although vacancies exist. At present three members of staff are rostered throughout the day and one qualified nurse with one support worker awake at night. The manager said that during induction and shadowing, new staff are supanumery to the staffing levels. Facilities for the safekeeping of cash and valuables exist at the home and the records checks corresponded with the balances held. Fire risk assessments are not currently up to date and must be reviewed; this will ensure that preventative measures are taken to reduce the risk of fire at the home. Other checks that comply with associated legislation are undertaken by outside contractors and include Portable equipments, lifts, hoists and gas safety checks. The Trust operates their own Quality Assurance system and a copy of the recommendations made through the audit was available. The manager undertakes a separate audit and surveys; face-to-face discussions with relatives are used to seek feedback about the standards of care at the home. Kilvie House DS0000020246.V359236.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 28 YES Are there any outstanding requirements from the last inspection? 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 YA9 Regulation 13(4) (c) Requirement The moving and handling risk assessment for one person must be reviewed to ensure that up to date techniques are used. Protocols for administering when required medications must be included in the medication guidelines Fire risk assessments must be reviewed to ensure that preventative measures to prevent the risk of fire are in place Timescale for action 30/07/08 2 YA20 13 (2) 30/07/08 3 YA42 13 (4) (c) 30/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Kilvie House DS0000020246.V359236.R01.S.doc Version 5.2 Page 30 - 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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