Inspection on 06/07/05 for Kilvie House

This inspection was carried out on 6th July 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kilvie House 13/05/08

Kilvie House 04/01/06

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 6 July 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Kilvie House Address 25 Downend Road Kingswood South Glos BS15 1RT 0117 9475858 admin@aspectsandmilestones.org.uk Aspects & Milestones Trust Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Peter Hayes Care Home with Nursing for Younger Adults 6 Category(ies) of LD Learning disability for 6 registration, with number of places Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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 23 February 2005 Unannounced 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 service user 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 clients.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. A variation of registration must be applied for in this regard. Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Please note due to profound, multiple disabilities, the majority of residents are unable to express their views verbally about the Home. As a consequence of this the inspector spent time talking to staff on duty about their roles, responsibilities. The inspector spoke to one registered nurse, two care staff, and the registered manager, about their roles and responsibilities, their training needs, and how they assist and support residents, and carry out their duties. Staff were also observed assisting residents with their needs, one resident was seen initiating conversation with staff on duty and it was apparent that staff and residents have built up ‘warm’ and close relationships. 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 reviewed. The internal and external environment of the home was seen. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 6 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 Standards Statutory Requirements Identified During the Inspection Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 7 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 standard(s) 2,3 The staff team meet resident’s range of care needs. EVIDENCE: Staff on duty demonstrated an in depth understanding, and sensitivity about, the complex heath needs of residents in their care. Staff on duty, explained they relied on resident’s body language, gestures, and long-term knowledge of the residents to try and understand their needs. Staff communicated with residents in a warm manner, using ‘humour’, and touch. To review how residents’ care needs are planned and assessed two care plans were inspected. The assessments included a range of information, and detailed each resident’s range of complex care needs of each resident. Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 8 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 standard(s) 6,7,9 Resident’s complex physical, mental health and social care needs are met by the staff who support people to live a varied, fulfilling life. EVIDENCE: To review how residents’ care is planned and implemented, two care plans were inspected. The care plans included a range of information, and showed how to support residents with a range of complex care needs. The care plans contained easy to follow information, and showed how best to assist the residents to meet their complex nursing care needs. Care plans also addressed psychological needs of the person, and recorded how to support a resident if they seemed to be distressed or upset in mood. In each plan of care was a profile of the person; staff had completed these profiles based on knowledge and observation of the residents. These included information such as what was important to the resident as well as things they did not like. The range of information written in the care plans should help to ensure residents are supported to meet their needs. The care plans seen had been signed by staff to demonstrate they had been reviewed and evaluated on a regular basis, showing the Home monitors resident’s changing needs. Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 9 Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 10 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 standard(s) 11,12,13,14,17 Residents are provided with a healthy, and varied diet, and are well supported to live a fulfilling life in the Home and the community. EVIDENCE: Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 11 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 or local activities centres. The staff must be commended for their continued commitment to ensuring residents are able to go on regular holidays. There are two residents holidays planned to coastal resorts in the near future. The menu record was inspected to ascertain if residents are being provided with 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; the meal consisted of a choice of tuna sandwiches on wholemeal bread with crisps, or baked beans with cheese on toast, demonstrating residents are offered a choice of meals. One member of staff was heard asking one of the residents what they would like to have for lunch, and tuna sandwiches was their choice. 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. Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 18,19,20 Residents are supported to meet their physical and emotional needs, and there is a safe system in place for the handling, administration, storage and disposal of resident’s medication. EVIDENCE: The procedures for the administration, storage and disposal of medication were reviewed with one of the registered nurses, to monitor the systems in place for the handling of medication. The medication administration charts of three residents were inspected in detail. There was a photograph of the resident maintained with each record, to ensure medication is dispensed to the correct person. 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 D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 13 Staff assisted residents in a good humoured and courteous manner, and staff evidently have built up close relationships with residents. The staff on duty communicated among each other, and evidently worked well as a team. Staff told the inspector how much they valued the relaxed working environment of the Home. Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 14 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 standard(s) 22,23 The Home aims to ensure residents are protected from abuse and harm, and there is a suitable system in place for representatives of residents to complain on their behalf. EVIDENCE: A copy of the complaints procedure for resident’s and their representatives to make a complaint on their behalf is on display on a wall in the entrance hall, and this is a well-frequented part of the Home. The procedure includes the contact details for the Trust and the area office of the Commission for Social Care Inspection, if someone is not happy with the outcome of a complaint investigated by the Home. The complaints record book was viewed to ascertain how the Home responds to complaints. There had been no new complaints recorded since before the last inspection. There are policies and procedures in place relating to the issue of protection of vulnerable adults from abuse. The Trust provide training to ensure staff are up to date in their understanding of the principle of the protection of vulnerable adults from abuse. Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 24-30 The Home is clean, safe, and satisfactorily maintained, and is suitable for meeting the needs of residents. 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 bathrooms 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 such as wall lights and mobiles seen in many rooms to provide additional stimulation and relaxation for residents. Bedrooms were decorated in different colours and this helped to create an individual feel to rooms. The environment was clean, tidy and satisfactorily maintained internally and externally. Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33, Residents are supported to meet their needs by skilled, and well-supervised staff. EVIDENCE: The staff duty record for shifts, for June and July 2005 was inspected to review how many staff is on duty to support residents to meet their needs. There is a minimum of three staff on duty for a day shift, consisting of two care staff and one registered nurse and two staff at night consisting of one registered nurse and one care staff. The number of staff on duty for each shift met the minimum staffing numbers required by the Health Authority staffing notice under previous Care Home legislation Staff demonstrated they communicate well, and support residents in a sensitive manner, and work well as a team. Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,40,41,42,43., The Homes policies and procedures help to protect the rights and best interests of residents, and there are systems in place to maintain the health and safety of resident’s staff and visitors in the Home. EVIDENCE: Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 18 Mr Hayes has many years experience working in senior management jobs, caring for people who have learning disabilities; he has also previously worked for a number of years as a tutor of student nurses. Confidential records are kept in the office and this room is kept locked when not in use ensuring residents confidential information is held securely. Generally records were satisfactorily maintained and in order. Other records have been referenced elsewhere in this report, demonstrating well organised management in the Home. The fire logbook record showed that the range of required fire safety checks were being carried out, and were up to date, helping to ensure the safety of people who are in the building. There are also regular health and safety checks carried out of the environment, helping to ensure that the building is satisfactorily maintained. There is a range of policies and procedures in place that support and guide staff in their care practises, health and safety matters, employment issues, and the general running of the Home. Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 4 x x 3 Standard No 31 32 33 34 35 36 Score x 3 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kilvie House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x 3 3 3 3 D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 20 no 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 Regulation Requirement There are no requirements arising from this inspection. Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Kilvie House D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 300 Aztec West Almondbury 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 D56 D05 S20246 Kilvie House V236854 060705 Stage 4.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!