Inspection on 18/09/06 for Kimberley Residential Home

This inspection was carried out on 18th September 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 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 Residential Home 08/09/09

Kimberley Residential Home 09/09/08

Kimberley Residential Home 18/10/05

Kimberley Residential Home 05/05/05

Kimberley Residential Home 09/12/04

Kimberley Residential Home 10/05/04

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

CARE HOMES FOR OLDER PEOPLE Kimberley Residential Home 40 Mickleburgh Hill Herne Bay Kent CT6 6DT Lead Inspector Mary Cochrane Unannounced Inspection 18th September 2006 09:00 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 Residential Home DS0000023458.V300166.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 Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kimberley Residential Home Address 40 Mickleburgh Hill Herne Bay Kent CT6 6DT 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) 01227 374568 admin@kimberley-care.com C&P Limited Mrs Amanda Jane May Care Home 31 Category(ies) of Dementia (30), Dementia - over 65 years of age registration, with number (30), Learning disability (1) of places Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be 60 years of age and above LD is restricted to one (1) person whose date of birth is 17.04.1942 Date of last inspection 18th October 2005 Brief Description of the Service: Kimberley Residential Home is a care home providing personal care and accommodation for 30 older people with dementia and one older person with a learning disability. It is owned by C & P Limited. The Managing Director, Kevin Post, also owns another home in the area. The home is located in a residential part of Herne Bay, with local shops and facilities. It is close to the town centre with all of its amenities. Herne Bay has a frequent bus service and there is a railway station. The home was opened in 1970 and consists of terraced houses joined together with an extension to the rear/side. There is a shaft lift although this does not give access to all areas. There are 21 single rooms and 5 shared rooms. There is an enclosed garden to the rear and planting areas at the front and side. The current fees for the service range from £384.05 to £470.00. Information on Kimberly Residential Home and how to obtain the latest CSCI report can be found in the homes Statement of Purpose and Service User Guide. Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which took place over one day. All the core standards were looked at during the visit. The homes registered manager was on duty and was available throughout the day. The owner of the home was also present and involved in the inspection process The service users and the staff on duty were helpful and co-operative throughout the visit. The registered manager has shown commitment to meeting the National Minimum Standards. The following methods of inspection and information gathering were used: one-to-one discussion with service users and staff, observing interactions, care interventions and activities, reading and discussing individual support plans, risk assessments, selected policies, medication procedures, and training programmes. The pre-inspection questionnaire was returned and feedback was received from service users, relatives and visiting professionals. Due to their diagnosis some of the service users have difficulty understanding and communicating verbally but through observation and looking at behaviours and documentation the majority seem content and secure within the homes environment. Relatives, staff and visiting professionals, supported this view. What the service does well: The registered manager of Kimberly Residential Home has the competency, experience and skills to manage the home to a good standard. She is able to demonstrate a clear sense of direction and leadership, which the staff and service users understand and relate to. The registered manager is enthusiastic and motivated to further develop and improve the service for the residents. The homes owner supports the registered manager in her role. Kimberly provides a relaxed, friendly and welcoming environment for service users to live in and for staff to work in. Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 6 Prospective service users and their families can visit the home and access the necessary information to help them decide whether or not Kimberly will be the right place for them to live. The staff do meet the physical and healthcare needs of the service users, there is regular input from specialists and G.P visits are frequent. The care staff on duty were seen to interact with the service users in a respectful and caring way. The service users who are able to verbalise reported that they were satisfied with the care they receive. They reported “the staff are very good and would do anything for them”. They felt that they received the care that they needed. They said, “ The staff are very kind and good”. The care staff were seen to be caring and respectful. They reported that they had developed good relationships with the service users and they were able to anticipate and meet the individual needs of the client group. After speaking to staff, the manager, relatives and visiting professionals the feedback is that the home meets the majority of needs of the service users. The premises are clean and homely. Service users are well kept, well dressed and cared for. What has improved since the last inspection? What they could do better: The home does need to develop a more person centred approach to care. Some aspects of care needs are fragmented and task orientated. The registered manager is aware of this and is presently developing ways to improve how care is delivered. Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 7 The home does provide activities for the service users. These could be further developed to include a more varied daily programme. At the moment all activities are in house and undertaken by the activities co-ordinator. Some service users said that they would like to go out more. The registered manager needs to ensure that all the medication administered and recorded by staff is done according to the homes policies and procedures. The home needs make sure that it monitors the dietary intake of the residents so any eating problems can be identified quickly and acted on. The home needs to develop a maintenance plan for the renewal and refurbishment to make sure the premises is maintained to good standard throughout. The home does need to further develop its quality assurance and monitoring systems to ensure that aims and objectives are being met and the home is run in the best interests of the service users. 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 Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 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 Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 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): 1,2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective and existing service users at the home do have all the information required to ensure that the home will be able to meet all their needs. Prospective service users can be sure that the home will undertake a full assessment of needs prior to arriving at the home. Service users places at the home are protected. The service users know what they are paying for. EVIDENCE: Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 10 The statement of purpose and service users guide is incorporated into one booklet. This is a clearly written document, which is easy to read and understand. It contains all the necessary information to assist service users and their representatives to make an informed decision as to whether the home is suitable and able to meet their needs. The manager could further develop the booklet by incorporating views and fed back from service users and their relatives/representatives. There are policies and procedures for assessment and admission to the home that include pre-admission assessment and trial periods. The home has its own assessment tool for this purpose, which explores all the relevant areas of care. The inspector looked at a sample of assessments. Some contained a lot more information than others but on the whole appropriate pre-admission assessments had been undertaken. All the service users have contracts and terms and conditions of residency on file. There is information about the fees charged what they cover when they must be paid and by whom. . Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff do not have daily access to all care planning information to assist them in meeting all the individual needs of the service users. The health needs of the service users are well met with evidence of good multi disciplinary working taking place. Medications procedures are not adhered to at all times. The privacy and dignity of the service users is up-held with wishes and views respected. EVIDENCE: The inspector looked at 6 care plans. There are individual care plans in place for each of the service users, which are developed using the information accumulated in the homes own initial assessment and joint assessments. The Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 12 care plans are of a good standard and contain the necessary information to enable staff to meet the needs of the service users. Risks are identified and how they can be minimised is documented. Plans are reviewed and up-dated at regular intervals. Unfortunately the plans are not used as a daily working document by the care staff team. Information about the daily lives of the service users is kept in various communal files. There are separate folders for when service users are seen by the other professionals (G.P’s, District Nurses, CPN’s, Chiropodists), when they have a bath, what activities they did during the day and a daily record file in which the information is mainly limited to when service users are taken to the bathroom. The home does need to develop a more person centred approach to care. Key working needs to be developed and promoted. At present care needs are met in a fragmented and task orientated way. This was discussed with the registered manager at the visit. The healthcare needs of the service users are monitored and met. There was evidence to show that the home access the required health-care services when necessary. The staff work towards promoting and maintaining the health of the service users and follow the guidance given by professionals. Each resident is registered with a local G.P. and any area of concern related to health is referred to the G.P. Any concerns about tissue viability are assessed so that appropriate treatment and intervention is commenced as soon as possible. At the time of the visit one service user had a pressure sore this was being treated twice a week by the district nurses (D/N’s). The inspector was able to talk to a district nurse during the visit. She reported that the home contacts local G.Ps and D/N’s promptly if there are health concerns. She reported that “the service users are well looked after” and from her experience staff are respectful and caring. It was reported that the home has a good and supportive relationship with the visiting professionals. All service users are weighed monthly and this is recorded. There are regular visits from the chiropodist, optician and dentist. Continence advice is sort as the need arises. The local Older Peoples Mental Health team is also accessed as necessary. The home uses the Monitored Dosage System (MDS) from Boots to administer medication to the residents. All staff who administer medication have received training. A list of staff competent to administer medication is kept. Sample signatures are also available. The medication is stored safely and the keys to this are kept on the person who is in charge of the shift. MDS were crossreferenced with MAR sheets and at the time of the visit the inspector did note some gaps where medication had not been administered. The staff on duty were not able to explain the reasons for this. Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 13 A lockable trolley is used to store medication, which is secured to a wall. There is a small secure room, which is used to store medication, and a fridge for drugs. Temperatures of the fridge are monitored and are within the required range. During the visit the inspector observed the administration of the lunchtime and evening medication. During the lunchtime medication round it was observed that drugs trolley was left opened and unattended for periods of time while the staff member took the medication to the service users in the lounge area. This was brought to the attention of the registered manager. During the evening medication round safe procedures were adhered to. The home also needs to develop clear written protocols in relation to medication to be administered as and when required. This will give staff direction and guidelines on when administer ‘as required’ medication. This also needs to include topical creams and lotions. Residents are well dressed in clothing appropriate for the season and appeared well kept. Staff were observed assisting service users in a caring and supportive manner and were seen treating the service users with respect and understanding. Some members of staff were observed demonstrating good body language and communication skills when interacting with the residents. Members of staff spoken to during this inspection confirmed an understanding and commitment to this aspect of care There are 5-shared rooms at Kimberley and there are screens available in each room to ensure privacy is maintained. There is a telephone area for residents’ use, which has a door for privacy. The registered manager confirmed that the home does care for residents who are dying if agreed with the general practitioner and community nurses. There is a policy regarding the death of a resident and relatives would be able to visit at any time. Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 14 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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not provide the service users with enough opportunities and facilities that enable them to maintain an appropriate and fulfilling lifestyle in and outside the home. Family links are encouraged and maintained wherever possible. Some service users are offered choice and flexibility within the home. The home needs to evidence that it provides nutritious and varied meals for the Service Users. EVIDENCE: . The home employs an activities co-ordinator who works 4 days per week 9am2p.m. she also undertakes some care duties. During the morning of the visit 5 of the more able service users were seen to be enjoying a game of dominoes and they were animated and stimulated. Other service users were seen to be Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 15 quite happy choosing to be independent and spending time in their own room or in a quiet area of the home. The majority of the service users were sat in the 2 large lounges of the home. There was little stimulation, or areas of interest in the room for the service users to focus on. Staff reported that sometimes they sat and talked with service users if they had time, played ball games or did exercises, but this was done on an adhoc basis. The home does need to develop an activities programme that is geared towards meeting needs, abilities and interests of the service users. The majority of staff spoken to said that they thought there should be more for the residents to do. Some service users said that they would like to go out sometimes. The registered manager needs to ensure that daily activities are planned in advance. This will allow both service users and staff to be prepared. It will also offer guidance and direction to ensure that the activities take place and are not just something that happens on the spur of the moment. At the moment there is no-one from the community coming into the home to offer entertainment or alternative activities. Visitors are welcome within the home at all reasonable times and no restrictions are imposed. 3 relatives reported that they could visit the home at any time and the staff were always friendly and helpful. It was observed during the inspection that service users are encouraged to speak to their relatives on the phone and staff were seen to be supportive of relatives when they visited. The service users who are able to verbally communicate felt that they were able to make choices in regards to their day-to-day lives. There are no restrictions as to where they could go in the communal areas of the home. The home does need to provide information for the service users/families on how to contact advocacy services who will act in their interests if necessary. Service Users are encouraged to bring their own personal possessions into their rooms and an inventory is kept on each individual file. The service users spoken to reported that they receive the care and support they need from the staff and they are treated well. One service user claimed that ‘’the staff will do anything for you” Service users reported that they felt confident and safe with the staff. The registered manager needs to be able to evidence that the routines within the home are flexible and varied to meet individual expectations, preferences and capabilities The service users, staff and relatives spoken to said that the food provided by the home is good and there is always plenty to eat. The inspector spoke to the Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 16 cook who has a planned four weekly seasonal menu. The menu only stipulates the main cooked meal of day, which is varied and nutritious. The cook orders the majority of the food, which is delivered. Fresh fruit and vegetables are delivered twice a week. Specialist diets are catered for. There is a cleaning rota in place, which is adhered to, and fridge temperatures are within the normal range. The environmental health officer visited last year and did not identify any areas of concern. The cook has been working at the home for 18 years and works 6 days per week Monday- Saturday and a member of the care staff team prepares the Sunday meal. The registered manager needs to make sure that a record is kept of all the meals provided and not just the main meal of the day. Evidence needs to be in place to demonstrate that service users are offered a choice if they do not like what is being served. The registered manager needs to ensure that a record is kept of food eaten and not eaten by service users. This will highlight along with nutritional assessments and regular weight checks if there are areas of need/concern that have to be addressed. It was noted at the inspection that a service user had experienced significant weight loss over a period of time. The G.P was aware and a nutritional assessment had been undertaken and the information transferred to a care plan. However there was no record of the meals the resident had been given whether or not they had been eaten or whether supplements had been offered. The registered manager needs to ensure that this information is documented and that information is not just transferred verbally between staff. The majority of staff were seen to assist service users with there meals in a caring and respectful way. Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system. Service users are protected from harm and abuse. EVIDENCE: The home had received 3 complaints since the last visit. The inspector was able to evidence that these had been dealt with according to the homes policies and procedures and satisfactory out-comes had been reached. The service users complaints are taken seriously and acted on. The registered manager needs to make sure that there is a copy of the complaints procedure displayed in a prominent position in the home. The home has the appropriate Adult Abuse policies in place and also a Whistle Blowing Policy. The staff that the inspector spoke to were aware the policy, felt confident to use if necessary and knew the appropriate action to take if they had to do so. The inspector was able to evidence from talking to the service users, relatives and staff and by looking at records and documentation that the service users are protected from abuse. The policies and practises of the home ensure that physical and /or verbal aggression by service users is understood and dealt with appropriately. Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements to the environment will enhance the service users quality of life. The service users are provided with a home that is clean and hygienic. EVIDENCE: The home provides a homely, friendly and safe environment. There are aids and equipment in place to meet the needs of the service users. There are some shared rooms and screens are provided for privacy. The residents have the choice to bring personal items into the home. The shared areas provide a choice of communal spaces and service users have the opportunities to meet relatives and friends in private if they wish. The home does need to produce a routine maintenance programme for the renewal of the fabric and decoration of the premises. The inspector did a Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 19 partial tour of the building and some areas especially hallways, landings and bathrooms did appear in need of redecoration. The bathroom looked at although serviceable did look worn and in need of up-grading. It was observed at the inspection that a service users bedroom was used as hairdressers. The inspector was informed that the resident had agreed to this and the issue is going to be addressed when the home expands. The home is soon hoping to expand into an adjoining house, which will offer the facility of 6/7 extra en-suite bedrooms. There will also be the facility to provide a separate room that can be used for hairdressing and other activities and the possibility of re-locating the laundry area. The present laundry area is in need of up grading and the home does not have a sluicing facility. The inspector was informed that this will be included in the new plans. Infection control policies are in place and staff have received the required training. There are the facilities available in all the appropriate areas for hand washing and the home has the appropriate facilities for the disposal of clinical waste. Soiled laundry is transported correctly in red bags and washed at the appropriate temperatures. The premises are kept clean, hygienic and free from offensive odours. Kimberley Residential Home DS0000023458.V300166.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff have a good understanding of the service users and positive relationships have been formed. The arrangements for the induction training of staff needs improving. Staff are able to demonstrate a clear understanding of their roles. All staff have received the required foundation training. Recruitment practises are generally sound but one area does need tightening up to ensure the service users are protected. EVIDENCE: The home employs a total of 21 care staff. The staff rota was seen, evidencing that 3 to 4 staff on are on duty per shift, plus the Manager, with 3/4 night staff night staff. In addition to this, the Home employs a cook who works 6 days per week, ancillary staff and a maintenance man who works 8 hours per week. The staff reported that they have developed good relationships with the service users and they are able to anticipate and meet the individual needs of the Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 21 client group. Service users responded positively to staff. It was observed that some staff are accessible and approachable to the service users and are able to exhibit good listening and communication skills. From speaking to some of the staff and from observing daily activities there was evidence to show that some of the staff are quite task orientated. This indicates that they may be inflexible and rigid with routines within the home. This was discussed with the registered manager at the time of the visit. NVQ training is on going at the home. 9 staff have achieved NVQ level2 and above and 2 staff are presently on the course. The home does have recruitment policies and procedures. The inspector looked at 5 staff files. Most of the files contained all the necessary information to ensure that procedure had been adhered to. 1 file did only have one reference. The manager was going to address this. The company presently stores all CRB’s in the administration office. The registered manager stated that all staff have an up-to date CRB in place and that no staff are employed until a satisfactory police checks are in place. The registered manager needs to ensure that a full employment history is obtained from all applicants and that any gaps in employment are explored at interview and a record kept. All staff files need to contain a photograph of the staff member. The home has a training matrix in place, which shows at a glance the training undertaken by staff members and gaps are easily identifiable. Training within the home is on going and staff are up-dated when necessary. The manager is keen to further develop the range of training opportunities. Staff reported that they are encouraged to develop their skills and knowledge. Mandatory training was seen to be up-to date for all but 3 members of staff and is on-going. Some specialist training is in place to ensure that staff have the knowledge to assist them to meet the varied and individual needs of the service users. Half the staff group have recently received dementia training from an out-side trainer and the rest were to attend shortly. Induction training was looked at and there was evidence to show that some members of staff had not completed their induction training even though they had been at the home for some time. The registered manager needs to ensure that all new staff complete induction training. Kimberley Residential Home DS0000023458.V300166.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. The home has registered manager in post who has the necessary qualifications, experience and skills to offer leadership guidance and direction. Quality assurance requires further development. The health, safety and welfare of the service users is promoted and protected. Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager is competent, experienced and skilled to manage Kimberly Residential Home. She has many years of experience working in care and has managed other homes in the past. She is committed to improving the standard of care for the service users. There is a strong ethos of being open and transparent in all areas of running the home. The registered manager has the skills, competencies and positive attitude to run the home effectively. She is able to communicate a clear sense of direction and leadership, which the staff and the service users responded to. The registered manager demonstrated that she is keen to develop her skills and knowledge in dementia and planning person centred care. Service users, staff and relatives reported that they felt valued and supported. The staff and service users responded in a positive, relaxed manner in the presence of the manager. The home has started to develop some quality assurance and monitoring systems to assess its performance. There is a questionnaire for residents and the inspector was informed that questionnaires have been sent to relatives and some have been returned. The home also needs to seek the views of other stakeholders who use the service. Action then needs to be taken to show that the home is improving the service that it offers having taken into account the results of the surveys. Quality Assurance needs to be further developed to include an annual development plan, systems which continually self monitor. The registered manager needs to follow the guidance in standard 33 of the National Minimum Standards. The home does not handle any finances of the service users this is done by relatives/representatives. Some staff reported that they have received some supervision. From looking at the evidence not all staff including the registered manager are receiving formal supervision. All levels of staff need to receive formal supervision 6 times a year. There was also no evidence to show that staff are having regular staff meeting. The manager and care staff confirmed this. Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 24 The home provides a safe environment for service users to live in and staff to work in. Good working practices ensure the home is free of hazards. The company’ has an induction programme and staff receive mandatory training which is on going and up-dated as required. Policies are in place to strengthen safe practices. All the relevant checks and inspection of equipment and system have been undertaken and were evidenced on the day of the inspection. An accident book is maintained. All fire checks were done. Water temperatures are taken and comply with regulations. Drug cupboard and fridge temperatures were also evidence and were within the stated ranges. The Manager is aware of RIDDOR and reporting incidences to the Commission under Regulation 37. COSSH products are locked away safely. Environmental risk assessments are in place. Kimberley Residential Home DS0000023458.V300166.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X N/A 2 X 3 Kimberley Residential Home DS0000023458.V300166.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 OP12 Regulation 16(m)(n) Requirement Discover service users interests and arrange a programme of activities to enable them to engage in local, social and community activities. The routines of daily living and activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. To ensure that there are effective quality assurance and quality monitoring systems in place, based on seeking the views of of service users,family and friends and other professionls involved in the service. To measure the strengths and weakness of the service and and ensure that the home is meeting the aims, objectives written in the statement of purpose. All levels of staff need to receive formal supervision at least 6 times a year and a record kept. Timescale for action 30/11/06 2 OP33 24 (1)(a) (b)(2)(3) 31/03/07 3 OP36 18(2) 31/01/07 Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 27 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 OP7 Good Practice Recommendations Care plans need to be used as a daily working tool. All the information on how service users needs are to be met needs to be brought together and a person centred approach developed. Staff need to adhere to the homes procedures for the administration and recording of medication. Protocols need to be developed for the administration of ‘ when required medication’. The home needs to keep record of meals provided and the choices offered to residents. Evidence needs to be maintained of meals eaten by the service users. The home needs to produce a maintenance programme with timescales. On-going renewal and redecoration needs to take place in areas of the home. The laundry room needs to be up-graded or moved to another location and a sluice facility developed. All new staff need to complete the induction training programme within the recommended time scale. 2 OP9 3 3 OP15 OP19 4 OP30 Kimberley Residential Home DS0000023458.V300166.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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. 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