Inspection on 08/06/06 for Kimberley Court

This inspection was carried out on 8th June 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 but made no statutory requirements on the home.

Other inspections for this house

Kimberley Court 16/07/07

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 Anchor Trust Crantock Street Newquay TR7 1JG Lead Inspector Mike Stokes Key unannounced Inspection 8th June 2006 09:30 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.V298396.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.V298396.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kimberley Court Address Anchor Trust Crantock Street Newquay TR7 1JG 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) 01637 850316 01637 877297 sharon.blackwell@anchor.org Anchor Trust 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.V298396.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 23rd March 2006 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)) 20, Mental Disorder over sixty five (MD (E)) 5 and Old Age (OP)36. This care home is part of the Anchor Trust organisation and 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 flat style accommodation and level access throughout the building and there are 2 passenger lifts. There are well cared for gardens at the front and rear of the building. There is a car park at the front of the building. Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Kimberley Court is registered to provide personal care and accommodation for 36 older persons. This was a key unannounced inspection to look at standards of care provided in the home. I arrived at 9.30 am and the inspection was completed over 2 consecutive days through talking with service users, staff, management, reviewing records, observing daily routines and discussing procedures and developments at the home. 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. Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 6 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.V298396.R01.S.doc Version 5.2 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. The registered provider will assess all prospective service users prior to admission; the home is providing appropriate information to assist service users and advocates in making an informed choice about where to live. A review of the existing statement of purpose and guide is required. EVIDENCE: The home provides care and accommodation for older persons and the majority are assessed as requiring support with mental health needs. Pre admission assessments are completed and appropriate consultation occurs with other professionals and agencies. Visits to the home are arranged to assist in the admission process and a month’s trial occurs before service users are provided with terms and conditions. These form a contract that includes the required information and states the room to be occupied. Service users are provided with a welcome pack that includes local service information, advocacy contact details and information about the Anchor Trust. An application to vary the categories of registration has been approved to include the admission of service users less than 65 years and an amended statement of purpose and guide is required to reflect changes occurring. Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. The home is providing care plans for all service users based on the assessment of need. Various health care elements of these plans are met regarding the involvement of multi disciplinary professionals and services provided. The personal and social care services provided to service users have improved since the previous inspection. Anchor Trust have increased staffing levels and made progress with the improvement plan but reported incidents are still occurring at a frequency that causes concern. EVIDENCE: The plans of care for 3 service users were inspected. The plans included appropriate information regarding the assessed needs of service users and various risk procedures intended to provide for service users welfare. The records demonstrate that service users have access to GP’s; community nursing staff and other support services as required. The administration of prescribed medication to service users was observed and recording procedures are satisfactory. A requirement to complete an analysis of falls and reportable incidents occurring at the home has been completed and consultation is occurring with the local PCT Falls Coordinator to ensure appropriate interventions exist for those at risk of falling. Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 9 A requirement to reassess the outcomes of the recorded plans for service users and to provide service users with the appropriate opportunities to access preferred activities, exercise and stimulation has been complied with. A full time activities coordinator has been employed. I observed a group session occurring at the home and discussed this work with the coordinator and staff. Positive comments were received regarding the development of this project to improve the quality of care for service users. Anchor Trust has made progress in the management of these issues but reported incidents are still occurring at a frequency that causes concern. There have been a further 24 regulation 37 reports received since the last inspection on 23/03/06. This is approximately a 12-week period and covers deaths, serious health conditions and falls occurring. There were 30 accidents recorded and 15 of these led to regulation 37 reports specifically for falls, where service users required attention. There have been 2 incidents where service uses suffered fractures during this period. A requirement is made for Anchor Trust to provide a further report to this Commission stating their proposals to manage these concerns and must include a review of staffing levels, consultation with other agencies and staff training to provide for service users welfare. Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15. Service users maintain contact with visiting relatives and friends at the home and service users are predominantly dependent on these contacts to access community facilities. The Anchor Trust has recently increased the existing staffing levels and improved opportunities for social activities occurring at the home. EVIDENCE: The registered person has complied with a requirement to reassess the outcomes of the recorded plans for service users. A full time activities coordinator has been employed to provide service users with appropriate planned opportunities to access preferred activities, exercise and stimulation. The support staff have received training in ‘dining with dignity’ and the main meal was observed to be presented in a calm and organised atmosphere within the dining room. The support staff offered individual support and assisted other service users as required. The chef and assistant chef discussed the menus, choice and special meals provided. Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The management and staff have an appropriate awareness of their responsibilities and use the policy and procedures at the home to assist in the protection of service users. EVIDENCE: The homes adult protection policy and procedure includes references to supporting staff in reporting concerns (whistle Blowing) and reporting allegations or incidents immediately to the Social Services (No Secrets) and this Commission in compliance with regulation 37. The senior carer stated that staff training and induction is provided in recognising and reporting concerns. These processes have been used at the home to ensure the ‘Protection of Vulnerable Adults’ procedures are used appropriately. Service users are supported in maintaining their personal finances and affairs through relatives and Power of Attorney processes. Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. A maintenance programme continues and the home was clean, warm and organised for the welfare of service users. The standard of the environment at the home is generally good, providing service users with comfortable bedroom and communal areas. EVIDENCE: The manager escorted me on a tour of the building and discussed the plans for the environmental refurbishment that will include structural changes to the dining room and lounge, safe access to the garden and patio area and the provision of new lighting, colours and furnishings that will improve the environment for service users. Safety locks have recently been fitted to doors leading to stairs that have been assessed as a risk to service users that may fall. Service users still have access to all parts of the home through the use of the passenger lift. A maintenance programme continues and the home was clean, warm and organised for the welfare of service users. There have been no structural changes since the previous inspection which noted that bedroom accommodation is provided through 14 rooms on the Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 13 ground floor and 22 rooms on the first floor level, the bedrooms are for single occupancy and 33 rooms have en suite toilet and shower facilities. There are 3 bathrooms and the majority of service users require assisted bathing due to dependency levels. The rooms are individually decorated and met the relevant standards. Service users can bring items of furniture and possessions to personalise their bedrooms. Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. The inspector observed practice, read various records and received comments from staff that clearly showed the increase in staffing and organisation has improved the quality of life for service users at the home, although the frequency of falls is still a concern. EVIDENCE: A requirement from the previous inspection report was made in the context of concerns regarding the frequency of reported falls and incidents that have occurred at the home. The management of Anchor Trust have improved the staffing levels since the last inspection. It is noted there has been 30 accidents recorded since this improvement in staffing levels and 15 of these led to regulation 37 reports specifically for falls, where service users required attention and 2 service users suffered fractures. A requirement is made for Anchor Trust to provide a further report to this Commission stating their proposals to manage these concerns and must include a review of staffing levels, consultation with other agencies and staff training to provide for service users welfare. Anchor Trust have provided a substantial programme of staff training in the previous 12 month period. The staff team are involved in appropriate NVQ training at various levels and other associated training relevant to the care of older persons. The manager stated that 8 staff had left in the previous 3 months due to normal reasons, a reinforcement of expected standards and disciplinary procedures. The recruitment of new staff was progressing and the manager wishes to retain good staff to provide stability and continuity of care. A Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 15 requirement is made regarding the recording and organisation of various records needed to demonstrate appropriate recruitment, induction and staff training and supervision profiles. The registered person must ensure that all staff have an appropriate CRB check and references that are recorded appropriately at the home. Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. The Anchor Trust have submitted an improvement plan and progress is made with the requirements raised in the previous report. An application is required for a registered manager to be in day-to-day control to show leadership and implement this plan. EVIDENCE: The Anchor Trust has recruited a manager with appropriate experience and qualifications. A requirement is made to submit an appropriate application. The issues raised have been discussed with the Anchor Trust management and requirements made have been complied with. The management have reacted to these concerns by immediately increasing staffing levels and providing an improvement plan. The Anchor Trust have employed Laing and Buisson to complete a quality audit in January 2006. The manager discussed the recommendations of this report and other methods used to seek service users views at the home. The manager is developing service user and relatives forums to develop good Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 17 communication, support and educational evenings. Regulation 26 reports that provide a monthly self-assessment on the homes conduct were not available for April and May 2006. Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 18 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 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 and 5 Requirement The registered person must provide an amended statement of purpose and guide to reflect changes occurring at the home. The registered person must provide staffing numbers and skill mix of qualified/unqualified staff that are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. The number of staff /hours in respect of service user needs should be based on guidance recommended by Department of Health. The registered person must ensure that all staff have an appropriate CRB check and references that are recorded appropriately at the home. The registered person must ensure the recording and organisation of various records is provided to demonstrate appropriate recruitment, induction, staff training and supervision profiles. DS0000028266.V298396.R01.S.doc Timescale for action 31/07/06 2. OP27 12 31/07/06 3. OP29 19 31/07/06 4. OP30 18 31/07/06 Kimberley Court Version 5.2 Page 20 5. OP31 8 The registered person must 31/07/06 submit an application for a registered manager who is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Requirement not met. 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 Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Kimberley Court DS0000028266.V298396.R01.S.doc Version 5.2 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. 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