Inspection on 16/07/07 for Kimberley Court

This inspection was carried out on 16th July 2007.

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 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

Kimberley Court 08/06/06

Kimberley Court 23/03/06

Kimberley Court 14/10/05

Kimberley Court 01/02/05

Kimberley Court 06/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Kimberley Court Kimberley Close Crantock Street Newquay Cornwall TR7 1JG Lead Inspector Melanie Hutton Key Unannounced Inspection 16th July 2007 10:00 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 Kimberley Court DS0000028266.V342683.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. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kimberley Court Address Kimberley Close Crantock Street Newquay Cornwall TR7 1JG 01637 850316 01637 877297 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) sharon.blackwell@anchor.org Anchor Trust Post Vacant Care Home 36 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (36) Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users to include up to 6 adults aged under 65 with dementia (DE) Service users to include one named person under the age of 65 Total number of service users not to exceed a maximum of 36 Date of last inspection Brief Description of the Service: Kimberley Court is a thirty-six bedded home on two floors which is registered in the categories of Dementia over sixty five (DE (E)) 13 beds, Mental Disorder over sixty five (MD (E)) 13 beds and Old Age (OP). This care home is part of the Anchor Trust organisation, which is a not for profit organisation. The home is situated in a cul de sac in Newquay, within walking distance of the main street and harbour. It is a purpose built building offering individual flatlet style accommodation and level access throughout the building. There are well cared for gardens at the front and rear of the building. There are 2 passenger lifts. There is a car park at the front of the building. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken on 16 July 2007 by two inspectors who arrived at 09.45 hours and left at 19.00 hours. The inspectors were assisted during the inspection by the manager, deputy manager and a deputy manager from another Anchor care home who is currently supporting the manager with the implementation of new systems. Service users and care staff were spoken with during the inspection. Records and the premises were inspected. Observation and case tracking were used as part of the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Further information should be included in the service users guide and statement of purpose to accurately reflect the care home and provide detailed information to prospective service users and / or their representatives. Full care needs assessments should be completed and available within the home to ensure that the needs of individual service users can be met by the home. The service users individual care plans should be developed to provide detailed guidance on how their care needs will be met. A daily record should be kept. The process to recruit an activities co-ordinator should continue and written information be maintained of the activities currently taking place within the home for individual and groups of service users. A record must be maintained of the food chosen and eaten by individuals. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 6 The complaints log for the home must be located and available for inspection or a new log in place to record any complaints made to the home and the action taken to resolve these. Any areas of risk to service users e.g. hot water pipes that are unguarded must be addressed. All staff must have regular supervision of which detailed written records are maintained. All areas of the home should be clean and free from odours including flat lets that are currently empty. The bathrooms of the home are stark and not homely in appearance, this does not provide a welcoming appearance or respect service users privacy and dignity. The Manager is aware of the gaps in the training provision; training is being prioritised for all staff. Staff must be provided with the skills and knowledge to meet the service users needs. The number of staff who have completed their NVQ is insufficient. Evidence of training must be available for inspection. The need for a permanent staff team is evident. Service user’s monies must be stored individually and not pooled. This should be readily available to them. Service users must be able to make choices and be consulted about restrictions that affect them. Entries in the care documentation referred to the use of restraint and bringing someone back into the home against their will. 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. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are not provided with sufficient information to enable them to make an informed decision about the home prior to moving in. Care needs assessments are not completed fully and in detail to demonstrate that the care home can meet the needs of the service user. EVIDENCE: The home provides information to prospective service users and their representatives within several documents; an Anchor organisational statement of purpose, a statement of purpose reflective of Kimberley Court and a service users guide. Copies of these documents are also held at the care home and were provided to the inspectors during the inspection. The statement of purpose provided to the inspectors on the day of inspection did not include full and detailed information for service users e.g. the address of the care home, the organisational structure of the home, the arrangements made for consultation with service users about the operation of the care home, the fire precautions and associate emergency procedures in the care home, the Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 9 arrangements made for contact between service users and their relatives, friends and representatives, the complaints procedure, the size of the rooms in the home, details of any specific therapeutic techniques used in the care home and arrangements made for their supervision and the arrangements made for respecting the privacy and dignity of service users. The service users guide provided to the inspectors on the day of inspection, did not demonstrate that prospective service users have access to the most recent inspection report, a copy of the complaints procedure or service users’ views of the home. The recent inspection reports are displayed in the reception area of the home. Care needs assessments are undertaken for service users prior to them moving into the home to ensure that their care needs can be met. The organisation has introduced a new system for recording care planning and this incorporates the care needs assessment for individual service users. Currently service users documentation and personal information is in the process of being transferred to this new system of recording and staff are being supported through this transitional period by the manager and a deputy manager form another care provision of Anchors. Service users records inspected identified that there were gaps in the recording of the care needs assessments with many lacking in detail and information. Kimberley Court does not provide intermediate care. Short periods of respite care can be arranged if there is an empty room available and following a care needs assessment. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 10 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 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans do not provide detailed guidance and information for staff to ensure that individual care needs of service users will be met. Limited evidence is available to demonstrate that service users have sufficient access to health care services. Medication procedures within the home protect service users. EVIDENCE: The inspector’s case tracked the records of six service users. As previously mentioned the home is currently in the progress of transferring all information to a new system of recording. This transition has not been successful and the staff are currently being supported by the manager and a deputy manager form another Anchor care home where this change has been put in place. Care plans inspected demonstrated that these are not regularly reviewed and do not consistently provide detailed information about the service users. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 11 There is little recording regarding social, leisure, spiritual or psychological needs and despite daily entries evidencing that some service users can demonstrate challenging behaviours, care plans do not provide guidance on strategies to manage this. Daily records are not maintained; an alert sheet details medical interventions. Risk assessments are undertaken including a moving and handling risk assessment, these provided varying detail. One care plan and risk assessment relating to the same service user contradicted each other in that the care plan stated the service user required the assistance of two carers and the risk assessment only one carer. Records relating to health care needs e.g. assessment tools were found to be incomplete and / or brief in many cases. One service user who appeared to have medium to high care needs from the available documentation did not have a waterlow assessment completed to identify the risk of pressure sores. One nutritional assessment identified that the service user had problems with eating due to their dentures but no appointment had been made with the dental department. No completed continence assessments were observed and general pads were seen in communal bathrooms and toilets. The assistant manager stated that pads were ordinarily stored in individual bedrooms so that the care staff were aware of which pads were for individual service users – this should be reflected within the care planning. One care plan observed was detailed and did provide specific guidance to care staff on the personal care to be provided in order to meet the assessed needs of the service user. Service users are provided with access to their general practitioner and records maintained of these visits and the reason for and outcome of each visit. A recent open evening was arranged for service users, their families to meet the newly appointed management team and health professionals e.g. the dentist and chiropodist were also invited to meet people. Medication was observed to be administered safely from a medicines trolley. Photos of each person accompany their medication sheet. The inspector was informed that original prescriptions are held for all medicines that are prescribed. A record is kept of all staff signatures. There is a controlled drugs facility; this was not inspected on this visit. There are Policies and Procedures relating to the administration and storage of medicines. Staff had not signed to confirm that they had read and understood them. The Senior Carers are completing a two-day training course provided by the Pharmacist. Medication is dispensed from a monitored dosage system which staff report works well. Medication administration records were observed to be correctly completed. One service user self administers their medication and is provided with a suitable lockable facility. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 12 Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 13 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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The activities provided in the home must meet the individual and collective needs of the service users over a full week. Service users enjoy the food that is provided. Service users must be consulted about any restrictions and enabled to make choices about how they live their life. EVIDENCE: The home is currently advertising for an activities co-ordinator. For two days of each week, the activities co-coordinator from another Anchor care home in Cornwall is present in the home and provides activities for the service users. During the inspection it was observed that activities were taking place within the communal areas. Two service users were involved with a photography session and the development of photographs that they took. A member of the care staff undertook a reminiscence quiz with a group of service users, during the morning. Following lunch, a quiz was played by a group of service users with the activities co-ordinator utilising the television and DVD player. This appeared a popular activity with service users continuing to join the activity throughout the session and providing opportunities for laughter. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 14 The manager and visiting deputy manager stated that other activities take place throughout the home, but limited recording is available to demonstrate this. Care plans do not always reference service users preferences and choices in the leisure activities they may like to partake in. During the inspection visitors were observed to visit the home and this was also reflected in the visitors book that is placed at the main entrance to the home. Service users monies are pooled and paid into a bank account. Entries in the care documentation referred to the use of restraint and bringing someone back into the home against their will. Service users are able to bring in personal possessions into their accommodation. Service users are able to choose where they eat their meals, with some eating in their own rooms and some at small tables in the lounge area. The majority of service users were observed to take their main meal of the day in the dining area of the home. Twenty eight seats were laid for the main meal of the day, during the inspection this was sweet and sour chicken or cottage pie. The dining room was observed to be spacious and pleasantly decorated with the tables attractively laid. Service users who sit at the tables are provided with visual examples of the meals to choose from or enabled to make their choice earlier in the day if they so choose. Pureed and liquidised meals are served in an attractive manner and the cook showed the inspector how vegetables are served in moulded shapes to be pleasing to the eye. Staff were observed assisting service users individually with their meals in a discreet and sensitive manner, sitting alongside them and offering choices as necessary. A choice of cold drinks is available throughout the day in the dining area through juice dispensers. The menus are regularly changed and have recently been amended following one of the catering assistants completing a BTEC qualification entitled cater craft. The catering manager stated that service users are included in the development of menus – no evidence was available to support this. A comments book is placed in the dining room where service users and / or their representatives or the staff include any comments made about the food provided. All service users spoken with during the inspection commented that they enjoyed the food provided. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 15 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 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users are not enabled to make complaints and not fully protected by the homes policies and procedures. EVIDENCE: The home has a complaints procedure within the policies and procedures file for staff to refer to. The statement of purpose and service users guide that was provided to the inspectors on the day of inspection did not identify the complaints procedure relating to Kimberley House. Within the welcome pack provided to service users regarding Anchor Homes a complaints procedure with the organisations contact details is included. The deputy manager was unable to provide the inspectors with a complaints log. The home has a policy and procedure regarding the protection of vulnerable adults – this is not in line with local multi agency policies and procedures. A further policy and procedure is included in the Induction training file. Further information is included within guidance from Anchor on their rights and responsibilities. Staff have been provided with training regarding the protection of vulnerable adults from an Anchor trainer, with a minority attending the Department of Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 16 Adult Social Cares (DASC) external training. The deputy manager stated that it is very difficult to obtain places on the DASC training courses. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Refurbishment is ongoing in the home with the communal areas safe and comfortable. The gardens are generally well maintained and provide a safe environment for service users to access. Bathrooms require personalising. Some areas of the home require thorough cleaning. EVIDENCE: The home is located close to Newquay town centre and is situated in its own grounds, providing secure access for service users to the garden and car parking for twelve cars. A gardener / maintenance person is employed by the homes and the gardens observed during the inspection were well maintained and attractive places to sit. There are closed in areas of storage at the rear of the home for clinical and household waste. A fire escape at the rear of the home is accessible through a flight of steps, these were noted to be overgrown with brambles in places. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 18 The entrance to the home and the communal areas are of a warm and welcoming appearance. All communal areas have recently undergone complete refurbishment. Some areas appear stark as pictures and ornamental effects have yet to be replaced. The deputy manager stated that it is intended that new pictures that have a tactile as well as visual purpose are to be purchased. The inspectors undertook a tour of the premises. In some areas an odour was noted and some toilets were in need of cleaning. Some of the empty flatlets are in need of cleaning. The deputy manager stated the workmen who were employed to decorate the home had recently occupied one flatlet that particularly required cleaning. Two empty flatlets had cigarette burns in the carpet. This was discussed with the deputy manager who stated that prior to a new service user residing in the flatlet it would be refurbished and the necessary decoration undertaken. Flats that are empty are generally unfurnished to enable service users to furnish them with their personal possessions – furniture is available should this be required. A guest flat is available on the ground floor for either relatives / friends visiting service users or Anchor employees from other parts of the country who wish to stay in the area. Service users bedrooms were observed to be clean and tidy and those people who spoke with the inspector were satisfied with the level of domestic assistance they receive. All doors to individual accommodation are lockable and service users were observed using the keys to their rooms. The communal areas were odour free and domestic staff observed to be cleaning throughout the day. The linen cupboard on the first floor was observed to be untidy with the clean bedding and pillows on the floor – the floor was dirty and needed cleaning. Bathrooms in the home provide assisted bathing facilities and some have showers in place as well as baths. The bathrooms in the main are large and clinical in appearance. In some of the flatlets hot water pipes run up the walls beside the toilets and were very hot to the touch. The laundry of the home is on the lower ground floor with direct access outside and provision to dry clothes outside. There are two washing machines which are of industrial appearance, have a sluicing facility but are small in size. Two tumble driers are also available. Care staff send the soiled linen to the laundry in large shopping type bags. IF the linen is particularly soiled it is sealed and washed in disposable plastic bags. The clean linen is returned to service users in plastic baskets, the shopping style bags are also included in these baskets. Provision is made for hand washing and gloves and aprons are available in this area. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 19 Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The Manager is aware of the gaps in the training provision, training is being prioritised for all staff. Staff must be provided with the skills and knowledge to meet the service users needs. The number of staff who have completed their NVQ is insufficient. Evidence of training must be available for inspection. The need for a permanent staff team is evident. EVIDENCE: The staff rota for the home was available for the day of inspection and three further weeks were provided for inspection. Currently the home has a number of care staff vacancies (80 hours per week). A recruitment day was due to be held on the following week. There has been a period of changes within the management team as noted during the last random inspection. Two care assistants are undertaking their induction process to become senior care staff to help address this and a manager has been recently appointed together with a deputy manager. The manager is currently going through the registration process with the CSCI. Domestic and catering staff are employed in sufficient numbers to ensure that standards relating to food, meals and nutrition are fully met and that generally the home is clean and tidy. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 21 The AQAA provided by the manager prior to the inspection states that there are now two qualified NVQ assessors in post and NVQ workshops have been commenced to assist the care staff with completion of their NVQ qualifications. There are 27 permanent care staff in post supported by five bank staff. Of these seven members of staff have NVQ level 2 or equivalent, with eight members of staff currently working towards obtaining this qualification. Staff files inspected demonstrated that a thorough recruitment process is undertaken prior to the appointment of staff including checks with the criminal records bureau and two references obtained. Interview records were observed. The inspectors were informed that all new staff are provided with induction training, however no completed records were available for inspection. The induction is a BTEC foundation award incorporating Skills for Care. The most recent member of staff had reportedly completed this within two weeks. Evidence must be available that staff are completing their induction. Food hygiene training had been provided over five sessions internally. The inspectors were informed that Anchor Trust likes to do their training internally. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 22 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): 31,33,35,36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user’s monies must be handled in the best interests of the service user. Quality monitoring systems must be established. All staff must receive regular supervision. EVIDENCE: The home has recently appointed a new manager who is currently undergoing the registration process with CSCI. The manager has many years experience in the management of care homes and as detailed in the service users guide and statement of purpose has completed the registered managers award and the NVQ level 4. She is supported in her role by the deputy manager, also recently recruited, who has completed the NVQ level 3. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 23 The manager has attended training courses to ensure that she is up to date in her own practice and skills. Service users and staff spoken with during the inspection, commented upon the changes in management within the home and all felt things had improved with the arrival of the new management team. The senior care staff have also undergone a period of change and further care staff are in the process of being inducted to the role of senior carer. The inspectors were informed that no feedback or service user’s surveys had been undertaken for some time. There was no evidence that views of families, visitors and stakeholders had been sought. The inspectors were informed that no visits had been conducted under Regulation 26. The home is being refurbished and the manager stated that the service users have been involved in the choice of furniture and decorating. The manager stated that a six weekly newsletter has been introduced to provide information to service users and encourage feedback to the staff. There is a policy and procedure relating to the safe handling of service user’s monies. Families can deposit personal monies for the use of the service users. However these are paid into a pooled account in the bank, not interest in payable in this account. Monies held in the home are held together. Records are kept of incoming monies, expenditures and the balance. Expenditures are receipted. The records showed that internal audits had identified small amounts of missing monies. The safe was observed to contain lost property and items that were not dated or receipted. Supervision records were inspected for a number of the care staff. Limited information is available in supervision records and the record does not always identify the content of the supervision session. In some instances the supervision appears to be reactive e.g. as a result of a complaint or concern raised as oppose to proactive. Twelve staff are booked to do a First Aid course on the 20th of August. The register of service user’s rooms and clinical information is located in the main reception accessible to anyone who wishes to read it. Accidents are recorded in an Accident book, however the pages are not being removed. Food hygiene training had been provided over five sessions internally. The inspectors were informed that Anchor Trust likes to do their training internally. The manager stated that maintenance of the portable hoists and lifts have been undertaken. The AQAA states that portable electrical equipment was last tested over twelve months ago and checks on the premises electrical circuits, fire fighting equipment, emergency call equipment, heating system and gas appliances have been undertaken this year. Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 24 Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 25 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 2 X 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 1 2 X 2 Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 5 Schedule 1 Requirement Timescale for action 01/12/07 2 OP3 14(1)(a) (b) 3 OP7 15(1) 15(2)(b) 4. OP12 16(2)(m) (n) It is required that the statement of purpose and service users guide be reviewed and developed to ensure that service users are provided with detailed information regarding the care home. It is required that the registered 01/09/07 person shall not provide accommodation to a service user at the care home unless the needs of the service user have been assessed by a suitable qualified or suitably trained person and the registered person has obtained a copy of the assessment. It is required that the registered 01/09/07 person shall prepare a written plan (“the service user’s plan”) as to how the service user’s needs in respect of his health and welfare are to be met and keep this plan under review. It is required that the registered 01/12/07 person consults service users about their social interests and about the programme of activities and demonstrate by DS0000028266.V342683.R01.S.doc Version 5.2 Kimberley Court Page 27 5 OP14 17 Sch.3 6 OP15 17(2) Schedule 4 (13) 7 OP16 17(2), Schedule 4 (11) 8 OP18 13(6) 9 OP26 13(4)(a) 10. OP35 20 11 OP36 18(2) written records that service users identified needs are being met. The registered person shall keep a record of any limitations such as restraint, agreed with the service user as to the service user’s freedom of choice, liberty of movement and power to make decisions. It is required that records are kept of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for service users. It is required that records are kept of all complaints made by service users or representatives or relatives of service users or by person working at the care home about the operation of the care home, and the action taken by the registered person in respect of any such complaint. The registered person shall make arrangements by training staff to prevent service users being harmed or placed at risk of abuse. It is required that the registered person ensure that all parts of the home that service users have access to are so far as reasonable practicable free form avoidable risks e.g. all hot water pipes guarded. The registered person shall not pay money belonging to any service user into a bank account unless the account is in the name of the service user. It is required that staff working at the care home are appropriately supervised. DS0000028266.V342683.R01.S.doc 01/09/07 01/09/07 01/09/07 01/12/07 01/12/07 01/09/07 01/12/07 Kimberley Court Version 5.2 Page 28 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. 5. Refer to Standard OP26 OP21 Good Practice Recommendations It is recommended that all areas of the home are clean and free from odour – even empty flatlets. It is recommended that the bathrooms of the home be refurbished to be more homely and welcoming in appearance. It is recommended that staff at the home continue to achieve obtaining NVQ level 2 or equivalent. For the personal effects in the safe to be sorted out and for the safe not to be used for lost property. For the fire records in the front reception to be removed to protect service user’s right to confidentiality. It is recommended that the portable electrical appliances be tested annually. OP28 OP35 OP38 Kimberley Court DS0000028266.V342683.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Devon Area Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Kimberley Court DS0000028266.V342683.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. 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