CARE HOMES FOR OLDER PEOPLE
Kimberley Nursing Home 51-53 The Avenue Surbiton Surrey KT5 8JW Lead Inspector
Alison Ford Unannounced Inspection 5th January 2006 11:30 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 Nursing Home DS0000026250.V274651.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 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 Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Kimberley Nursing Home Address 51-53 The Avenue Surbiton Surrey KT5 8JW 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) 0208 390 1557 020 8390 4372 Partnership of Parkin, Blown and Blown Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability over 65 years of age of places (38) Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st September 2005 Brief Description of the Service: Kimberley is registered with The Commission for Social Care Inspection to provide nursing care for up to thirty-eight older people. Accommodation is arranged in a mixture of single and shared rooms over three floors. There is a large lounge and dining room and an attractive well-maintained rear garden, which is well used by the residents. All areas of the home are accessible to residents, including those who may have limited mobility, and a passenger lift, specialist adaptations and equipment have been provided. The home is situated in a quiet residential road in Surbiton and there is off street parking to the front of the property. Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This second, unannounced, inspection of the year 2005/2006 took place over four hours and was conducted with the representatives of the home, as the current owners are no longer living in England and the Registered Manager has recently left. There were lengthy discussions regarding the future management of the home and the progress being made to comply with previously issued requirements. During the visit a partial tour of the premises was undertaken, several of the residents were spoken to and also five staff members. Discussion centred on ensuring that residents felt safe and well cared for during this period of transition and that they felt their needs were being met. During the course of the two visits, all of those standards considered by The Commission to be key to the inspection process, have been assessed and this report should be read in conjunction with the one produced following the inspection undertaken on 21st September 2005. Since the last inspection, no complaints have been received about this service. What the service does well: This home provides a safe and homely environment for its residents who were all very appreciative of the staff, many of whom have been there several years. Although most of the home requires redecoration and refurbishment all of those that were spoken to agreed how lovely the staff were and how well looked after they were. Comments were made “nothing was too much trouble” and that “ it was a lovely place to live “and “you can always say what you like” and” everyone always gets on well together.” All the residents commented how much they had enjoyed the recent celebrations that had occurred over the Christmas period and how lovely all the decorations had been. Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better:
As detailed in this report much of the home still requires redecoration and refurbishment. Carpets are worn and shabby, wallpaper needs replacing, some ceilings need repainting and wheelchairs are still being stored in the sitting room. The home is without a Registered Manager although strenuous efforts are being made to recruit a suitable person and the clinical responsibilities of the home are being very well managed by the senior nurses. Once this role has been filled there will need to be a commitment to staff training and development including supervision and appraisal. In view of all of the problems experienced recently by the home the timescales of any requirements that were not directly related to the health and safety of resident’s has been extended to allow them to be complied with. Please contact the provider for advice of actions taken in response to this
Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 8 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 Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 9 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): These standards were not assessed at this visit EVIDENCE: Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9,10 The arrangements that are in place for delivering personal care ensure that residents can be sure that their dignity and privacy will always be respected and medication procedures are in place to protect them. EVIDENCE: During the inspection staff were observed treating residents with respect and dignity and residents confirmed that this was always so. Comments were received about how caring staff were and that they “were always kind to everyone”. All personal care is undertaken in resident’s rooms and screening is provided in shared rooms. Medication records and storage were assessed and found to be in order Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 11 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): 12,13,14,15 Activities within the home are organised in a way that suits the residents and visitors are always made welcome so that relationships can be maintained. Meals are served that are suitable and nutritious and so maintain the health and wellbeing of residents. EVIDENCE: Residents confirmed that activities are provided which suit their needs and they are able to choose whether they wish to participate. Some explained that they prefer to remain in their rooms and watch television or read. They said that their relatives and friends are always made welcome when they visit. Residents agreed that the food served was very good; they are visited by the housekeeper in the morning, and informed of the meals that will be served and offered a choice. Most of the residents eat together in the dining room although they are able to stay in their rooms if they wish to. A tour of the home illustrated that residents have been able to bring personal possessions in with them from home.
Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 12 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): These standards were not assessed at this inspection. EVIDENCE: Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 13 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, Although it is clean, a programme of redecoration and refurbishment would make the home a more pleasant environment for residents to live in. EVIDENCE: The majority of the home, both bedrooms and communal areas, still requires redecoration and refurbishment. Carpets are worn and shabby, wallpaper needs replacing, some ceilings need repainting. No rooms have a lockable facility for the use of the residents. Wheelchairs are still being stored in the sitting room and could pose a safety hazard. On the day of the inspection the home was clean and tidy and free from odour. Automatic door closers, which operate in the event of a fire, need to be fitted to the bedroom doors of those residents wishing to keep them open however, a date to undertake this work has now been arranged.
Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 14 In view of the problems that have been experienced by the home timescales for this work to be completed have been extended. Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 15 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, Residents can be sure that there are always sufficient numbers of staff on duty to meet their needs. EVIDENCE: Since the last inspection staffing numbers have increased and staff agreed that this allowed them to spend more time with residents. Once the management arrangements are finalised in the home there will need to be an emphasis on staff training, supervision and appraisal and these issues are already being considered. Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 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): 31,34 Residents cannot be confident that they currently live in a home, which is managed by a suitably qualified and experienced person who will safeguard their interests although they can be reassured that the home is financially viable and that they will be able to remain there a long as they need to. EVIDENCE: The home is currently without a Registered Manager although strenuous efforts are being made to recruit a suitable person. Clinical responsibilities are being very well managed by the senior nurses in the home. Since the last inspection, residents can be reassured that documentation has been produced as evidence of the financial viability of the home and this has been seen at meetings with the homes representatives. Recent visits have been received from The Fire Safety Officer and The Environmental Health Officer and an assurance was given that the minor concerns raised had been dealt with.
Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 17 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X X X X Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 18 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 5(1) Requirement The Registered Provider must ensure that the service user guide is updated to reflect the current situation in the home and that it contains all of the information as specified in Regulation 5. (Previous timescale 01/12/05 not met and now extended) The Registered Provider must ensure that there is a programme of maintenance and redecoration of the home and that a copy of this is sent to the office of The Commission for Social Care Inspection. (Previous timescale 01/12/05 not met and now extended) The Registered Provider must ensure that devices are fitted to bedroom doors, which cause them to close automatically in the event of a fire. (Previous timescale 01/12/05 not met) Timescale for action 30/03/06 2. OP19 23 (2) (b) (d) 30/03/06 3. OP19 13(4)(c) 28/02/06 Kimberley Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 19 4 OP22 13(4) (c) The Registered Provider must ensure that suitable storage facilities are available for wheelchairs. (Previous timescale 01/12/05 not met and now extended) The Registered Provider must submit plans outlining how at least 50 of care staff will obtain an NVQ level 2 qualification. (Previous timescale 01/12/05 not met and now extended 30/03/06 5 OP28 18(1)(a) 30/03/06 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 Nursing Home DS0000026250.V274651.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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