Inspection on 04/01/06 for Kilvie House

This inspection was carried out on 4th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kilvie House 13/05/08

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 09/07/2008.

CARE HOME ADULTS 18-65 Kilvie House 25 Downend Road Kingswood South Glos BS15 1RT Lead Inspector Melanie Edwards Unannounced Inspection 4th January 2006 09:30 Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 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.V273684.R01.S.doc Version 5.1 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.V273684.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kilvie House Address 25 Downend Road Kingswood South Glos BS15 1RT 0117 9475858 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 6 Category(ies) of Learning disability (6) registration, with number of places Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate up to 6 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 6th July 2005 Brief Description of the Service: Kilvie House is a care home operated by Aspects & Milestones Trust, formerly Frenchay & Southmead Care Trust. The home provides nursing care for a mixed resident group of up to six 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 six single rooms. Whilst there is no en-suite provision, all rooms have a wash hand basin. 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. Car parking is available. Planning permission is currently being sought by the Trust to extend the existing building to provide two additional bedrooms with additional bathroom and dining room areas. Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Please note due to profound and multiple disabilities, many of the residents are not able to express their views directly about the Home. Because of this staff were interviewed about their roles and responsibilities. The registered nurse, and two care assistants were consulted as part of the inspection process, about their different roles and responsibilities, their training needs, and how they assist and support residents. Staff were also observed assisting residents with their needs. A range of records relating to the day-to-day running and management of the Home were inspected. A selection of resident’s care records and care plans were also inspected. Wendy Kirby a second inspector accompanied Melanie Edwards on the inspection. What the service does well: What has improved since the last inspection? What they could do better: Residents would benefit if all care plans are formally reviewed and updated regularly to indicate that staff monitor their changing care needs. It would also be beneficial if a programme of redecoration and repair of the inside of the Home were carried out. Specifically two bedrooms require repainting where paintwork has become worn and marked, and one bedroom carpet needs to be replaced, as it is very worn. Also the quality of life for residents and staff would be enhanced if the carpet in the lounge were replaced as areas of the carpet have become stained. Also one of the chairs in the lounge requires the cover replacing as the fabric has worn through on one armrest to the plastic underneath. A training need that must be addressed to assist in maintaining health and safety of people inside the building is to ensure all staff are provided with regular fire safety up date training. Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 6 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. Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 7 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.V273684.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3, The Home is assessing and meeting residents’ needs. EVIDENCE: To find out how the Home assesses residents range of care needs, two residents assessment records were inspected. The assessments included information about the resident’s complex care needs. Assessments had been written based on the idea of person centred planning which means staff try and put the views, wishes, likes and dislikes of residents at the centre of all care provided. The staff on duty discussed with the inspectors how they assist residents and try and understand what their needs and wishes may be. All the staff conveyed a good understanding of residents’ range of needs. Staff also demonstrated a good understanding of how to try and support residents to meet their needs. Staff will rely on understanding and interpreting residents’ body language, facial expressions, gestures, and long-term knowledge of them to try and understand their needs. Staff and residents were observed sitting in the lounge, and staff communicated with residents in a warm and good-humoured way. All the staff on duty were patient and sensitive in manner when assisting residents. Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9, Residents’ changing needs are met, and residents are well supported to take risks in their daily lives both in and out of the Home. EVIDENCE: To find out how staff assist residents with their care needs, two residents care plans were inspected. Care plans are written from the perspective of person centred planning meaning residents needs, likes and preferences are central to all care that is planned This should help to ensure care is individualised and based on the involvement and participation of residents. The care plans contained a range of information, and demonstrated how to support the residents to meet their health care needs. Care plans also addressed how to respond to residents if they seemed to be distressed or upset in mood. One resident’s care plan had been formally reviewed and updated regularly by one of the registered nurses helping to demonstrate residents’ needs are monitored and kept under review. However the second care plan had not been formally reviewed or updated for eight months. Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 10 As already referred to in the report due to residents profound and multiple disabilities they cannot verbally communicate their wishes. As referred to previously, staff work at trying to interpret non-verbal communication from the residents. In discussion with staff on duty, staff demonstrated a clear awareness that they understood the need to uphold residents’ rights and choices in their daily lives how ever difficult this may be. Residents are also well supported by staff from the Home and day care staff to attend a range of day care services and facilities in the community. Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,17 Residents are well supported to live a fulfilling life both in and out of the Home, and they are provided with a healthy varied diet. EVIDENCE: Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 12 The staff on duty explained to the inspectors how they regularly support residents to go out to the local community and to day care services. There is also a minibus that the Home can use for trips with residents. Residents regularly go out for coffee, as well as to nearby pubs, and other social venues thereby helping to ensure a varied and fulfilling life. There was also detailed information written in daily records showing residents access community activities such as the shops, the pub, hydrotherapy sessions, bingo sessions, and other local activities. The menu record was inspected to find out if residents are offered a well balanced diet. There were choices of dishes recorded for each day and the menu was nutritionally well balanced, and varied. The lunchtime meal was seen being served which consisted of a choice of cheese sandwiches and vegetable soup. One member of staff was heard asking one of the residents what they wanted to have for lunch. Staff assisted residents with their food in a sensitive manner helping to ensure the meal was a relaxed experience. The kitchen was inspected to see if food is stored and prepared in a safe environment. The kitchen was clean, tidy, and well organised. The Home was awarded a South Gloucestershire Council food safety award in 2005,helping to demonstrate staff follow best food safety practices. Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Residents are well supported to meet their physical and emotional health needs, also there are safe systems in place for handling, administrating, storage and disposal of resident’s medication. EVIDENCE: The procedures for the administration, storage, and disposal of medication were inspected. The medication administration charts of three residents were inspected. There was a photograph of the resident kept with records to help to ensure medication is dispensed to the correct person as well as a medication administration profile, which details the preferred way that residents like to have their medication administered. The medication administration charts were legible, up to date, and contained the signature of the dispensing registered nurse, demonstrating resident’s medication is administered safely, the reasons for any omissions had also been written on the charts. Up to date records were also being kept of all medication being received into the Home, and medication being returned to the issuing pharmacy, showing there are safe systems in place to monitor how much medication is held in the Home. Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 14 Staff assisted residents with their personal care needs in a good humoured and sensitive manner. As has been previously referred to in the report, residents care plans include a range of detailed helpful information, stating how best to support residents to meet their physical, mental, social and spiritual needs. There was also a record kept for each resident of when the person had seen the GP, the chiropodist and other health care professionals. The records helped demonstrate that residents physical care needs are being addressed. Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 There are procedures, and training provided that help to protect residents from harm or abuse. EVIDENCE: In discussion with the inspectors all of the staff on duty demonstrated a good understanding of their responsibilities to ensure the residents in their care are protected from any undue harm or risks of abuse. There are Trust policies and procedures in place relating to the protection of vulnerable adults from abuse. Also staff attend training run by Mr Hayes who is one of the Aspect and Milestones Trust designated `protection of vulnerable adults from abuse’ trainers to help to ensure they are up to date in their understanding of the principle of the protection of vulnerable adults from abuse. Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 The Home is homely, comfortable and clean and the necessary specialist equipment is provided for residents needs. However, the Home is only partly satisfactorily maintained. EVIDENCE: Kilvie House is close to local shops and residents can easily access local amenities. It is a converted residential style property in a quiet residential area. The entrance of the building provides very easy access for wheelchair users and there is similar access to all areas. There are grab rails positioned along the corridors and manual handling lifting aids in the bathroom and toilets. The bathrooms are satisfactory in size to provide easy access and the baths are specially adapted to assist residents. The standard of the decoration and the quality of fixtures and fittings was satisfactory. Rooms had been furnished and decorated to reflect resident’s different interests. There were visual stimulation aids as well as relaxation aids including wall lights and mobiles seen in rooms to provide additional stimulation and relaxation for residents. Bedrooms are decorated in different colours and this helps to create an individual feel to rooms. The environment was clean, and tidy. However two bedrooms require repainting where paintwork has become worn and marked, and one bedroom carpet needs to be replaced as it is very worn. Also the health and safety of residents and staff would be maintained if the carpet in Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 17 the small lounge were replaced as large areas of the carpet has become stained One of the chairs in the lounges requires the cover replacing as the fabric has worn through on one of the arm rests to the plastic underneath. Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35 Residents are cared for by skilled staff who are well trained and supported by management. EVIDENCE: All of the staff that were on duty were observed helping residents in a good humoured and warm manner Staff on duty communicated with each other, and were working well as a team. To review how many staff are on duty for each shift, the duty record for the previous four weeks was inspected, for nursing and care staff. There was a minimum of one registered nurse recorded on duty at all times and two care assistants in the morning, with two care assistants and one registered nurse in the afternoon. At night there is one registered nurse and one care assistant on duty. The manager works a set number of supernumerary management hours each week as well as regular shifts to keep up to date with day-to-day matters in the Home. Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,42 The Home is well run and there are systems in place that generally help protect the health and safety of residents, staff and visitors. EVIDENCE: The staff all spoke very positively about Mr Hayes and how supportive he was. They also said that the team was `close’ and very supportive of each other. There are regular staff meetings, and staff said Mr Hayes always listened to their views. Confidential records are kept in the office and this room can be locked when not in use ensuring residents confidential information is held securely. The fire logbook record showed that the range of required fire safety checks were being carried out regularly. However one member of staff had not attended recent fire safety update training, which is necessary to ensure all staff are aware of up to date fire safety practices and procedures. Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 20 There are a range of policies and procedures in place that support and guide staff in health and safety matters within the Home, which helps to maintain the safety of residents, staff and visitors. Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 21 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 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X X X X 2 X Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 22 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 2 Standard YA6 YA24 Regulation 15.2(b) 23.2(b), (c) Requirement Timescale for action 04/02/06 3 4 YA28 YA42 23.2(c) 23.4(d) All residents care plans must be reviewed and updated regularly. Forward to the Commission for 04/02/06 Social Care Inspection an action plan for the replacement of the two carpets and the repainting of the two bedrooms walls. Replace the fabric covering on 04/03/06 the lounge chair identified at the inspection. The staff member identified at 04/02/06 the inspection must attend fire safety update training. 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.V273684.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Kilvie House DS0000020246.V273684.R01.S.doc Version 5.1 Page 24 - 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. 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