Inspection on 08/09/09 for Kimberley Residential Home

This inspection was carried out on 8th September 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC 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 09/09/08

Kimberley Residential Home 18/09/06

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 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Kimberley Residential Home 40 Mickleburgh Hill Herne Bay Kent CT6 6DT Lead Inspector Eamonn Kelly Key Unannounced Inspection 8th September 2009 11:40 DS0000023458.V377626.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Kimberley Residential Home DS0000023458.V377626.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 08700 518677 home@kimberley-care.com C&P Limited. Mr Kevin Post. Mrs Amanda May Care Home 36 Category(ies) of Dementia (36) registration, with number of places Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th September 2008 Brief Description of the Service: The service provides support and accommodation for up to 36 people. The registration is specifically for the support of people with dementia. The premises are close to town centre amenities, to the sea-side and to public transport services. The brochure states that seven of the bedrooms have an en-suite facility; 26 single bedrooms and 5 shared bedrooms are located on the ground and first floors. A passenger lift assists access to the first floor. Onstreet car parking is available. Residents, staff and visitors have the benefit of a garden. The current fees, as outlined in the brochure, “begin at” £460 a week for permanent private residents and £505 a week for respite care residents. Weekly fees for Local Authority funded residents are £413. This includes a “top-up” of about £17 a week and this sum is redeemed from the resident by the Local Authority where they are able to do so. The brochure states that there are additional charges. “In addition to our weekly fee, extra charge is made for private physiotherapy, newspapers, toiletries, chiropody and hairdressing. This list is not exhaustive: if you require an indication of price for a service or item do not hesitate to ask”. The website www.kimberley-care,com includes a reference to further additional charges: these are stated as being “Transport, escorting to appointments and hospital visits”. Prospective residents and their advocates are entitled to a copy of a written guide (Statement of Purpose and Service User’s Guide) to the service to enable them to make a decision about entering residential care and choosing a residential home that suited their health and social care needs. This is available on request from the manager. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is No Star. This means that people who use the service experience poor quality outcomes. The inspection took place on 8th September 2009 between 11.40 am and 7.25 pm. The methodology used to produce this inspection report includes reference to the AQAA (annual quality assurance assessment) submitted in June 2009 by the owner (Mr Kevin Post) and information accruing from meetings with the manager (Mrs Amanda May), owner and members of staff on duty over two work shifts. There were meetings with four residents and three visitors. Observations of most residents took place at different times of the day. The profiles of three residents were assessed in some detail, discussed with the manager and relevant care plans seen. The AQAA outlined some of the areas that have been improved for the benefit of residents and areas of practice that either needs further development or such development is imminent. Registered care services submit an AQAA to the Commission once a year. The inspection included a visit to all parts of the premises. Some records used for supporting residents were checked. These included resident’s individual care plan folders, risk assessments and staff files. The outcomes of the previous inspection report were checked. Checks were also made of information known to the Commission about the service. In keeping with the Commissions policy of looking closely at specific regulations and standards from time to time some emphasis was placed on this occasion on how well the service meets Standards 7 and 8 (service user plans and associated support), 16 and 18 (complaints and protection), 27-30 (staffing) and 32, 33, 37 and 38 (management and administration). The previous report contained two requirements. One related to the need for completion of staffing checks before new members of staff started work. The other was “the manager must ensure that staff training in the mandatory subjects and in adult protection and dementia is kept up to date and valid. Up to date staff training is needed to fully protect the clients”. It was found that the recruitment procedure had been improved but the requirement for better staff training to support people who have dementia remained outstanding. There were other shortfalls identified relating to staffing Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.2 Page 6 issues principally that there were far too few staff on duty to meet the support needs of highly dependent residents within a large and dispersed environment. This report highlights the need for action to be taken to enable staff to develop a greater understanding of supporting people with dementia. This is particularly important because of the service’s registration and statements made in the Statement of Purpose that the service provides specialist support for “Ladies and Gentlemen with Alzheimers and Dementia”. The report contains other requirements as shown below and some recommendations on better practice are included in the main report. What the service does well: Although evidence showed that activities are not consistently provided, residents are helped by activity coordinators to remain mentally and physically active. Residents are encouraged to keep contact with their relatives and friends. Procedures are in place to help protect residents from abuse. The premises are broadly suitable for the care of frail older people. Bedrooms are personalised by residents and their advocates where they wish to do so. Residents and others have the benefit of a passenger lift. There are a number of communal areas for people to walk around and to relax in comfort. The garden is suitable for people with disabilities. Residents and visitors reported that the cook provided good meals. What has improved since the last inspection? The AQAA stated that more emphasis has been placed on activities. Mr Post referred to better procedures now in place for protecting vulnerable people. Parts of the premises have been improved and some resident’s bedrooms have been refurbished. A conservatory has been upgraded and a concrete ramp added. Records seen at this inspection showed that procedures for recruitment have been improved in that the home now ensures that CRB/POVA checks are taken up in all cases. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.2 Page 7 What they could do better: This report contains five requirements and three recommendations. The second requirement comprises two elements: these are the need for adequate numbers of staff to be on duty to meet the assessed and changing needs of residents and for appropriate training to be in place that addresses the needs of residents as described in the Home’s Statement of Purpose. Otherwise, there are requirements for: • care plan to be prepared for each resident when they enter residential accommodation and for such plans to identify resident’s needs and how the needs are to be/being addressed. Provision of door locks on resident’s bedroom doors with recorded risk assessments where, for purposes of safety, such facilities have been withdrawn. Improvements to the premises in addition to those underway as described in the AQAA for the benefit of staff and residents. • • The registered manager and registered provider should advise the Commission of notifiable incidents without delay. Recommendations are made in the report relating to the need for consideration to be given to improving the consistancy of activities for mental and physical stimulation of residents. There are also recommendations relating to ensuring that the way the service is managed is effective and to ensure that information contained in written information about the service is clear. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.2 Page 8 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 9 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.V377626.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Prospective residents and their supporters receive initial advice and guidance to help them assess the facilities and suitability of the home. A care plan folder is not begun immediately following admission to formally draw together all the identified disabilities and illnesses of prospective residents and to compile goals of care for staff to implement. EVIDENCE: Prospective residents and their representatives receive assistance and guidance to help them decide if the home is able to meet their support needs. The website www.kimberley-care.com contains information about the service Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 11 and a copy of a Service User’s Guide is available to prospective clients and their advocates. Mr Post stated that all new residents, whether privately funded or funded by a Local Authority), receive a personal contract that contains information on the rights and responsibilities of both parties (resident and provider). The manager carries out an assessment of prospective residents support needs with assistance where necessary from Social Services care managers. Most residents have support needs associated with the on-set of dementia and many have substantial mobility problems and other disabilities. The Commission expects a care plan folder to be prepared when admission is agreed. This would outline the support needs of the prospective resident and how these needs would be met. A review of care plans for recently admitted residents revealed that such care plan folders were not prepared for 10 residents who were admitted over the past two months. Further information about this shortfall in service delivery is contained in the next section of this report. The pre-admission report prepared by the manager at the initial assessment stage provided useful insights into how residents are supported at this stage. The three copies seen contained good information about resident’s current state of health and how they are supported. The downside was that this information (and that provided by SSD/health services where residents were Local Authority funded) was not converted into individual care plans on which to base staffing levels and plans for day-to-day support and intervention plans. Neither would it be easy, in the absence of individual support plans, to measure and record changes in health during the initial two months of their residency and implement changes on the results of such review. It was stated that potential residents may not always visit the home prior to taking up residence. However they (and their representatives) are invited to do so. The home admits residents for respite care. It does not admit people to receive intermediate care to enable them to recuperate after hospitalization and return home. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7-11. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive support on a day-to-day basis to meet their healthcare and social support needs. This support is not maximized by the failure of the service to maintain an individual care plan for all residents from the time they enter residential accommodation. Some care plan records do not fully identify the needs of residents and the detailed level of support that should be provided by staff. There are some practices that do not subscribe to the privacy, dignity and safety of residents. EVIDENCE: Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 13 Care plan records seen for three residents contained good information about residents support needs and how these are being met. They did not contain good personal profiles of residents but the activities coordinators are helping residents on an individual basis to produce these. A resident produced a profile based on staff research of his service in the army and it was apparent that this work has been of benefit to him. One of the three care plan folders had the resident’s photograph on the front page but the photograph spaces on the other two were blank. Three individual care plan folders were checked as part of a “case tracking” exercise. According to the manager, care plans are an increasingly effective operational tool for staff. The evidence is that members of staff are using care plans to identify the changing needs of residents and record how support should be provided. Residents care plans have a great deal of information about their support needs. In particular, risk assessments in each residents personal file identify the relevant issues associated with his/her continuing support and, in the examples seen, have recently been updated. Two major shortfalls in service provision relate to the way individual care plan folders are maintained. These could have a negative impact on the safety of residents and the ways members of staff work with clients in alleviating their illnesses and conditions. In the previous section of this report, reference was made to how ten residents do not have an individual care plan. It is the normal practice of the service for no care plan to be produced for residents who may not be staying at the service after care manager reviews between 6 and 10 weeks after admission. The procedure is as follows: The manager receives a care manager INP (individual needs assessment) and, in many instances, a detailed Home Treatment Team assessment. The latter is a detailed description of the prospective resident’s conditions and support needs at the stage when a decision has been taken to seek residential support for the person. The manager makes her own assessment and produces a Pre-admission Assessment statement. When the resident takes up occupancy, the manager prepares a written risk assessment. In the examples checked during the inspection, this risk assessment identified the major risks associated with the support of the new resident. However, this alone is not sufficient for the on-going care of residents. It is not until after the visit by a care manager that, between 6 and 10 weeks later, a decision is taken on the permanency of the resident and then a care plan is compiled. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 14 Continuing failure to compile an individual care plan for each resident is not in the best interests of the resident or members of staff. The Commission expects registered services to prepare such plans for all residents immediately after admission. This includes those admitted for respite support. These individual care plans are expected to develop from the pre-admission assessment carried out by the manager supported by any other records and information provided from health and social care sources. Carers complete daily records in respect of important aspects of residents health and changes in health or disposition. These issues were said to be discussed during staff changeover to enable in-coming staff to be aware of changes in residents temperament or health. At the time of the inspection, a district nurse reported her concerns to Social Service’s Adult Protection relating to potential lack of care for a resident with multiple pressure sores, the most serious of which were Grade 4. The investigation relating to this is ongoing. Discussions about the profiles of three residents and how they are supported suggested a level of understanding of and respect for clients but the lack of staffing numbers and sufficient training made it difficult for staff to meet resident’s needs. Where difficulties occur in the continuing support for some residents, there was evidence that care managers and family members are involved in reviews and any necessary changes in the levels of support. In meeting with some residents and observations of most, it was clear that they were dressed properly and, for example, men had shaved where it was their practice to do so. There were significant shortfalls in some areas of practice and premises. For example, a resident was in the toilet in full view between the lounge and front door. There were insufficient staff available to prevent this but when someone realized staff intervention occurred. Bedroom doors have had the lock “keep” removed. There is therefore no option for residents to lock their doors using, for example, suitable locks that can be opened from both sides in an emergency. This has both a safety and privacy implication for residents. Mr Post said that the lock “keeps” had been disabled for the protection of residents. Care plan folders included information that GPs visit as necessary and members of staff sometimes bring residents to GP surgeries. There are separate charges made to the resident for this service. The services of district nurses are routinely obtained. Difficulties in obtaining access by residents to dentists were said to have been overcome. Residents Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 15 have good access, according to profiles of residents discussed during the inspection and records checked, to local NHS community services. There is close contact with local PCT nurses who, for example, provide and change dressings. The manager outlined how careful consideration is given to residents before, during and after they hospital stays. The method of administering medicines was not checked during this inspection. The previous inspection report indicated that the manager audits medication procedures on a regular basis. The manager explained on this occasion how medications are administered and how unwanted medicines are recorded and disposed of. MAR sheets are completed at the time of administration. A photograph of each resident was said to accompany their MAR sheet. In the case of residents receiving respite care, a MAR sheet was said to be completed manually to control and supervise their medication administration. The manager said that only those members of staff who have received specific training are allowed to administer medication and update MAR sheets. She was advised, as part of the planned new approach to providing better training and support for staff, to consider whether a medicine supplier is the best source of staff training and whether the 13-week distance learning plus tutor assessed training provides better safeguards. In one of the three care plans checked, the information about his condition, why he reacted to his surroundings in the way he does and how staff should work with him was not accurate and up-to-date. In any event, there was not the availability of staff to properly help the resident. In another instance, the doors of two resident’s bedrooms have large printed signs showing the names of another resident who has a bedroom on another floor. The notice is an instruction to the resident that his bedroom is elsewhere. This is neither in the interests of that resident or of the residents occupying the two bedrooms. In another bedroom, the owner has placed a signed notice to staff relating to aspects of the resident’s laundry and clothing. These are examples and indications that senior members of staff have insufficient knowledge of how to work effectively with people with dementia and of how to use care plan records to plan interventions and support procedures. An important declared aim of support is to help residents remain as independent as possible. This involves encouraging them to move around on their own with any necessary staff observation. Generally for this purpose, residents are encouraged to not use wheelchairs within the premises but they have access to wheelchairs when they go out. It was stated that members of staff help residents who have hearing aids to keep them in working order and they encourage them to continue using the aids. Records indicate that residents weights are recorded monthly or more Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 16 often if necessary. The home has purchased a sit-on weighing scales. GP or dietician involvement is said to be sought where there are concerns. Care plans seen and discussion of profiles of residents indicate that good endof-life planning is carried out. This includes more recent improvement in the ways residents wishes are discovered and how these are recorded in care plan records. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive some support on a day-to-day basis to remain mentally and physically active and alert. An activities coordinator was helping in this respect. Residents were not receiving specific support at the time of the inspection that complied with the claims contained in written information compiled by the home. EVIDENCE: Residents may receive visitors at any reasonable time and the service encourages this continuing contact. Members of staff stated that efforts are continuing to be made to involve residents family and friends in helping with day-to-day activities. Members of staff had a good understanding of each residents personality and disabilities. They communicated well with residents who have disabilities. Potential problems with this communication and interaction with residents who Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 18 have dementia (in relation to how an agency carer was coping) were brought to the attention of the owner and manager. The AQAA stated that residents and family members are encouraged to say what they feel and to give their views about any issue they feel affects them. An activities coordinator gave examples of particular activities promoted by the service. These examples suggested that residents are helped in a number of ways to remain mentally and physically active. This included staff assisting residents on a one-to-one basis, helping them to walk about the premises including using the stairs and passenger lift, provision of books and newspapers, talking to them, providing music and helping residents visit the garden. The AQAA stated that activities include: hand massage, manicures, painting, knitting, cooking, gardening, games, puzzles, seated music and movement and Montessori based activities. The activities coordinator showed how records of such interventions are maintained with the intention of identifying activities most likely to interest particular residents. One such example seen was where a resident had been provided with a book containing the results of research of his army career. This was clearly of great benefit and significance to him. During the inspection, there was a positive atmosphere and carers were working actively with residents when they were not engaged in household activities. The downside was that, with such few members of staff on duty during the day, this was seen to place exceptional pressure on those staff. There are several communal areas throughout the premises and residents may choose which area they wish to use. The manager outlined how she ensures that detailed nutritional assessments are carried out and recorded in care plans. In the absence of care plan for some 10 residents at the time of the inspection, this information is not always formally recorded. A sit-in weighing scales is used to monitor changing weights. Weights were said to be taken and recorded at least once a month. The cook keeps written information about residents food intake. In two instances discussed, residents made good recoveries after they took up residence when their health was failing rapidly at that stage. The manager outlined how she places a priority on looking closely at how residents are supported before, during and after hospitalization and how she has become alert to possible problems in hospitals that have adopted end-of-life pathways. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 19 The evening meal was observed in part during the inspection. Some residents were assisted. There was a hot component provided at this meal. A similar meal was given to 29 people and one resident obtained a different lunch because the cook knew what she liked and disliked. The ambiance of the dining areas was not special with plastic tablecloths used and minimalist tableware provided. Individual meals were transported to residents who are unable to leave their bedrooms (or had expressed a wish to remain in their room). Cold and hot drinks were served to residents in lounge areas and bedrooms mid-morning and mid-afternoon. The AQAA contained detailed statements about the levels of support given to residents to remain physically and mentally active. This included references to how activities co-ordinators provided such support and how one of the registered providers has introduced new techniques in this respect. It stated that there are plans in place to extend the support for residents. The AQAA also stated that a Church of England service with Communion offered takes place monthly and a Catholic priest also visits two clients regularly. Between 11.40 am and 7.20 pm on 8th September 2009, the following observations were made. An activities coordinator was at the premises until 2 pm and she provided a brief outline about activities provided. There were 30 residents who have high support needs at the home. Until 2 PM, there was one carer on duty supported by an agency carer. The manager was working on shift until 8 pm. The manager frequently works longer shifts when there are too few care workers. In the afternoon, an additional carer was on duty. The Statement of Purpose claimed that there are 5 carers on duty during the day. Observations were taken at intervals in the afternoon. During a one hour period, two of the three residents in the smaller lounge area were constantly sleeping in their chairs. The third had a visitor. In the main lounge, fifteen of seventeen residents were slumped in their chairs and were unattended. Two residents had visitors. For over an hour, the observations showed that a resident sat in a chair in the main dining area with his head on a dining room table. Staff walked past him when when they were carrying out household work. At around 5 pm, a member of staff escorted the resident to his bedroom. A resident and a visitor were using the garden. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 20 A resident was in his bedroom asking for food. The manager said he spends a great deal of time in his bedroom. There was a musty type of smell in the room. The resident’s care plan did not reflect his disabilities and support needs. The manager agreed that there was a shortfall in how the resident was being supported. Later in the evening, residents began moving about the premises and staff prepared the evening meal. The AQAA stated: “We have recently further improved our activities with our clients. We now have three dedicated activity coordinators, 2 working every Monday - Friday morning”. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. It is the stated intention of the service to protect residents from abuse by the vigilance and expertise of staff. Complaints received by the Commission indicate that the service is experiencing difficulties in reaching this objective in full. The continuing poor staffing levels and relatively poor training support provided to staff are contributing factors. Some aspects associated with the premises contribute to lack of privacy and safety. EVIDENCE: The manager stated that members of staff, residents and visitors are aware of the complaints procedure and that all comments about the service are welcome. It was said that residents and visitors are involved in saying how improvements would be of benefit to them. One way of doing this is through quality assurance questionnaires sent to families, advocates and health professionals. According to the manager, visitors are closely involved in all aspects of the service and a copy of the complaints procedure was conspicuously available. Members of staff were said to receive training in matters associated with POVA and the manager said she was confident carers would understand if abuse was Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 22 occurring and how they should report it. She said that she and senior members of staff have a good knowledge of adult protection procedures followed by Social Services departments. The manager was also aware of the new protection service, the ISA (independent safeguarding authority) and its implications for staff and others. The Commission received a complaint in August 2009. Two complaints were received by the Commission in the past year and these were referred to Mr Post and Mrs May to investigate. A serious incident that led to the death of a resident has been investigated by the Police and remains the subject of a Safeguarding Adult’s inquiry by Kent Social Services. In relation to the more recent complaint received by the Commission, the issues raised were checked as part of this inspection. At the time of the inspection, a district nurse reported their concerns to Social Service’s Adult Protection and the concern is being further investigated by the adult protection group. The manager and owner advise the Commission of incidents affecting resident’s health (notifications) as required by Care Home Regulations. The evidence is that the Commission is not notified of all relevant incidents. For example, the AQAA stated that, in the year to June 2009, ten residents died at the premises and five died at a hospital. During this period, the Commission had 3 notifications, two of which were notifications of a resident’s death. This means that we are not able to show that the service notified the Commission of 13 deaths. Regulation 37 notifications are extremely important for monitoring purposes and it was concerning that the service had 15 deaths in one year and we had not been advised of the circumstances relating to all of these. The 2009 AQAA stated that questionnaires to clients representatives who respond to the manager. It stated also that the views of health professionals are formally obtained and that the views of the Kent Care Homes Association have been sought. Recruitment procedures have improved over the past year. Residents are at risk because of the poor staffing levels. As stated elsewhere in this report, the written Resident’s Guide claims that there are five carers on duty during the day. At the time of the inspection, one carer employed by the service and one agency carer were on duty to support 30 older people with very high support and personal care needs. It is also relevant that this support must be given in large and diverse premises. The level of training given to staff to justify the claim that specialist care is given to peole with Alzheimers and dementia is not in place and the evidence for this is contained in this report. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 23 The AQAA stated: “Our last inspection occurred during a period where staffing was not at its best level and we were struggling to maintain a good standard”. The evidence was that staffing on this occasion was worse than during 2008. This was agreed by the manager and owner. All bedroom doors have had the lock “keeps” removed. This does not provide any resident with the option of locking his/her bedroom door. Each individual’s capability has not been adequately assessed (please refer to earlier example) and an appropriate goal of care in this respect entered in the care plan folder for that resident. This situation has safety and privacy implications for residents. The registered responsible person for the service and the manager were aware that the Commission expects suitable locks to be fitted that can be opened from both sides in an emergency. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 26. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The premises are generally suitable for use by frail older people. Improvements to the premises are taking place. Shared bedrooms are not well equipped. Storage facilities throughout the premises are not good. The removal of part of the door locks on all resident’s bedroom doors does not improve the safety and privacy of residents. EVIDENCE: Radiators are covered for the safety of residents. Some hot water outlets accessible to residents are not temperature controlled as they should be. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 25 The AQAA contained declarations relating to safety checks and associated safety certificates being in place and up-to-date. There are 26 single and 5 shared bedrooms on the ground and first floors. Seven bedrooms have an en-suite facility. The premises have a passenger lift. A tour of the premises revealed some issues that need to be addressed for the benefit of residents: Some of the shared bedrooms were not equipped well but the shared bedroom used for respite care was better furnished. Some had hard floor covering that had not been specifically laid to meet the needs of residents with, for example, severe continence difficulties and shown in individual care plans. The communal sinks were not curtained for resident’s privacy. Two commodes were located in some of these rooms. Older hospital mobile screening was placed in the rooms although the registered manager stated that these are not used. Bedroom doors had a frosted glass panel. There was a net curtain on some of the panels. It is likely that light coming through the panel at night could keep residents awake. As mentioned earlier, all door-lock “keeps” have been removed. A keep has been refitted to the door where a serious incident occurred and which was the subject of Police investigation at the time of the inspection. A carpet cleaning machine was left unattended in a corridor. This was one of the issues brought to the notice of the Commission by a complainant in August 2009. The laundry is equipped only with two domestic type washing machines and a domestic tumble drier. The provider has told the Commission that there is also a commercial tumble drier in an outhouse. The staff room was being used for storing laundered and unlaundered clothes. The 2008 inspection report identified the need for improvement of laundry facilities but this has not taken place. The treatment room, used by district nurses and other health visitors, was being used for storage of large quantities of continence pads. This room was also being used by a hairdresser who visits once a week. There were traces of urine smells in two bedrooms. One bedroom, where it was said a resident spends most of his time, had a musty smell. This was mentioned to the manager during the tour of the premises. The manager said that great efforts are made to keep the premises clean at all times. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 26 Two toilets do not have an associated hand-washing facility. In one of these cases, there are plans to refurbish it. A printed sign in a bathroom instructed staff not to leave communal toiletries but a supply of such toiletries were stored there. Several carpets have been replaced, other flooring surfaces repaired, and several client bedrooms have been redecorated. A conservatory at the rear of the premises has been renovated with a concrete ramp added. Planning permission is being sought to replace some 18 wooden windows for UPVC double glazed units over a period of 5 years. Residents, staff and visitors have the benefit of a number of communal areas and to a newly landscaped garden. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 27 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27-30. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents did not have the benefit of being supported by adequate numbers of qualified members of staff. EVIDENCE: Three staff files checked during the inspection indicated that all new members of staff complete an application form, 3 written references are taken up, CRB checks are completed and induction/supervision/some training follows. The manager has an up to date list of staff available showing names of staff, the CRB reference number, date of check and a reference to the outcome. The example of the induction procedure seen showed that the procedure is being updated so that it meets Skills for Care standards. The written guide to the home’s services and facilities claims that there are five care workers on duty during the day. This guide is the formal statement made to prospective residents and their advocates at the point of admission to enable them to make a judgment about entering residential accommodation. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 28 Residents and their advocates are entitled to be able to trust such a written undertaking as the basis for the subsequent contract between the two parties. During the inspection in 2008, there were fewer staff than necessary on duty to meet the assessed and changing needs of residents. During this inspection, only one employed care worker was on duty and an agency care worker attended from mid-morning. The manager was on a work shift until 8 pm that day because of the staffing shortfalls. There are a range of support staff employed by the home but the poor level of care staff was of concern during the inspection. The AQAA stated that “Our last inspection occurred during a period where staffing was not at its best level and we were struggling to maintain a good standard”. During the inspection, Mr Post and Mrs May acknowledged that there were staff absence difficulties that affected staffing levels. Members of staff confirmed that the service has become accustomed to reduced staffing levels. A complainant advised the Commission that it was difficult to find a member of staff to assist residents when they needed assistance. Mrs May is working on a staffing matrix to enable all members of staff to gain an NVQ qualification and to undertake skills/knowledge development. The home is registered for people with dementia but not all carers are appropriately trained in this area. As stated elsewhere in this report, examples have been noted of poor practice for supporting people with dementia. In the three instances where staff files were checked, none has completed significant training to provide such specialist support. One member of staff had attended an introductory session on dementia run by Kent County Council. Another had completed a training session entitled “Yesterday-Tomorrow: Training in Dementia”. The manager and owner were advised to put plans urgently into place to enable them and all care workers to undertake an appropriate training course in dementia that would give them the level of skills and knowledge needed”. Elsewhere in this report, examples are shown of instances where the approach to supporting people with dementia was inappropriate. Taken together with poor staffing levels where the priority is to provide basic support for people at the home, the claims made in the home’s Statement of Purpose are not being met. Following the inspection, Mr Post advised the Commission that he was taking steps to locate suitable specialist training for all staff in dementia care and that these would be followed by appropriate training in the major topics (medication, infection control, food and nutrition). Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 29 The home’s induction procedure is conducted by a nurse external to the service. This person also is contracted to supply aspects of training. This person then signs off the induction checklist and the evidence is that there is a conflict of interest in the two roles. The manager is not fully in control of the whole procedure and the owner and manager were advised to address this shortfall. Mr Post said that he was contemplating further in-house training initiatives based on short sessions for staff using videos and other aids. He was advised to concentrate on improving how members of staff were introduced to mandatory topics and to move forward using tested courses in the fields of dementia care, infection control, food and nutrition, and medication administration. The manager said she would review how induction and training if other topics were being carried out. The manager holds the full first aid certificate and most members of staff hold the accredited first aid certificate. The AQAA stated that 50 of care staff have qualified to NVQ Level 2 or above and more are working towards this. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 30 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents do not have the benefit of living in a residential home where there is a clear sense of direction. EVIDENCE: Mrs Amanda May, the registered manager, has the qualifications and experience to manage the service and she has done so for a number of years. The evidence during the inspection was that the manager is not able to influence a number of important areas of operation on a short term and Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 31 medium term basis and this was supported by statements by the registered manager during the inspection. The AQAA refers to “delegation” of responsibility to others for some aspects of the manager’s duties. At the end of the inspection, it was brought to the notice of the manager and owner that the registered manager is responsible in law for all aspects of how the service is conducted and that the areas of operation that have been taken out of the manager’s control are leading to poor consequences for residents and members of staff. The AQAA stated that Mrs Helen Post is now responsible for refurbishment and decoration and activities for residents. According to the registered manager, the issues relating to the poor standard of shared bedrooms were outside her control. The registered manager also stated that the issue of door locks and missing “keeps” likewise were the responsibility of the registered providers. An example emerged during the inspection where the manager was not involved in some aspects of recruitment. The registered manager gave an example where Mrs Post wished to provide homely medications direct to a resident and did not agree with the manager that GP intervention was necessary first. The previous report stated that care should be taken to ensure that the registered manager had the required number of supernumerary hours for management and administration work. On the day of the inspection, the manager was working as a carer until 8 pm because of staff shortages and on 11/09/09 (when the inspector phoned the home) was likewise working a late shift to 8 pm due to staff shortages. At the end of the inspection, the owner and manager were advised that the Commission would expect the manager to work full time on management and administration because of the large number of residents and their high dependency needs. There would obviously be many times when the manager would have to intervene in the day-to-day activity of actively supporting residents and the AQAA acknowledges this. Examples of major shortfalls that must be urgently addressed as part of a management review are: 1. Care plans for all residents must be in place and maintained from the point of admission. 2. The required numbers of care workers must be on duty each day. 3. The position relating to bedroom doorlocks must be reviewed and suitable action taken to enhance resident’s safety and privacy. 4. A programme of specialist training for staff in dementia care must begin without delay. It is acknowledged that, during a phone call to the service on Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 32 11/09/09, the manager said that Mr Post had authorized this programme to begin. 5. All care plans should accurately reflect the needs of residents and there should be adequate numbers of trained staff in place to meet the goals of care contained in each care plan. 6. There should be sufficient numbers of staff in place with associated expertise and skills to provide suitable mental and physical stimulation for residents. 7. The Commission must be made aware without delay of notifiable events at the service. The manager stated that members of resident’s families or their recognised advocates hold responsibility for dealing with resident’s finances. Mr Post explained how the home operates a quality assurance system and that feedback is either invariably good or excellent. This contrasts with the outcome of this inspection when considering the current Safeguarding Adult’s inquiries, previous AP inquiries and referral of concerns by the Commission to the home for investigation. The AQAA contained declarations that all necessary safety checks have been carried out. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 33 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 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 1 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 1 2 1 2 x x x x 2 STAFFING Standard No Score 27 1 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 1 1 x 3 x x 1 Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 34 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard 1 OP7OP7 Regulation 15 (1) and (2) Requirement Care plans were not in place for 10 of the 30 residents, only admission documents that last up to 2 months after admission until it has been confirmed that they are permanent residents. In cases where care plan were in place, the needs of residents were not sufficiently identified with goals of care applied and reviews carried out. A care plan must be prepared for 01/02/10 each resident when they enter residential accommodation and these plans must identify resident’s needs and how the needs are addressed. 2 OP27OP2 7 OP30OP3 0 27-30 There were only 2 care staff on duty (carer and agency carer) when the inspection took place. The report evidences how residents were not receiving the support they needed because of very low staffing numbers working with people with high support needs and in large and DS0000023458.V377626.R01.S.doc Version 5.3 Page 35 Timescale for action Kimberley Residential Home dispersed premises. The evidence is contained in the report that care workers and senior members of staff are not receiving the specialist training, particularly in dementia care, that they need for the professional support of residents. Staffing: The manager and registered provider must ensure that there are sufficient staff on duty with the right experience and qualifications to support residents. Personal development for staff: The 01/04/10 manager and registered provider must ensure that procedures are in place to enable staff to acquire further skills and qualifications that are relevant to the work they undertake. 3 OP24OP2 4 23 3. All door keeps have been removed from residents bedroom doors. This is not in the interests of resident’s safety or privacy. The manager and registered 01/04/10 provider must ensure that the premises are suitable for people who use the service. This means that, in this instance, doors to resident’s private accommodation are fitted with locks suited to their capabilities and accessible to staff in emergencies. The fact that residents may have dementia or other healthcare difficulties is not a reason for de-activating door locks in all bedroom locations. This issue must be one of those that form part of the initial assessment and it must be included in the person’s care plan. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 36 4 OP19OP1 9 16 and 23 The manager and registered provider must ensure that people who use the service are in safe surroundings that promote their wellbeing. There is evidence in this report that some of the shared bedrooms were not equipped well, that residents may be being kept awake at night by light coming through the door panel, that there is no door locking facility throughout the premises (with associated risk assessments and entries in care plans where the facility is withdrawn), that there are storage problems for equipment, that infection control facilities need to be improved and that laundry facilities are not effective. The owner and manager were 01/04/10 advised to address the issue of improving these aspects of service provision for the benefit of residents, staff and visitors. This means that the shortfalls associated with the premises need to be addressed as well as premises improvement underway as described in the AQAA. 5 OP37OP3 7 37 The registered person must give notice in writing to the Commission without delay of occurrences that have a serious affect on residents. These notifications relate to death, illness and other notifiable events. 05/01/10 Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 37 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 OP12OP12 Good Practice Recommendations There are relatively poor activities for assisting towards the mental and physical stimulation of residents. The AQAA refers in detail to Montessori-based activities being introduced and the responsibilities for provision of mental and physical stimulation of residents being removed from the manager in a process of “delegation” of responsibilities. The evidence was that, on a particular day, residents were not receiving the opportunities for mental and physical stimulation to which they are entitled. Although an activities coordinator was on duty until 2 PM on the day of the inspection, the evidence was that residents, observed at 3 locations at the premises, were not receiving the attention they needed. There are a number of factors that need to be identified by senior members of staff as to why this is happening. The owner and manager were advised to review the effectiveness of the ways that residents are helped to remain active and alert through the provision of leisure and social activities. 2 OP32OP32 The pattern of management whereby responsibility for some aspects of essential procedures are not under the control of the manager (eg. premises upkeep, activities for residents, recruitment) is not in the best interests of staff or residents. The previous inspection report stated that care should be taken to ensure that the registered manager had the required number of supernumerary hours for management and administration work. In a service providing support to such a large number of people with high dependency needs within large and diverse premises, it would be expected that the registered manager would need to be full-time to meet the exigencies of the service at all times. The shortfalls in many areas of operation evidence this need to improve the management structure. DS0000023458.V377626.R01.S.doc Version 5.3 Page 38 Kimberley Residential Home People who use the service are entitled to believe that the person in charge of the service is managing in an effective way. This means that the manager ensures that all aspects of the service are managed appropriately with responsibility for most management and administration matters resting with that person. 3 OP1OP1 People who use the service are entitled to full and clear information in written information (eg. Statement of Purpose and brochure) about weekly fees and other charges that apply. The brochure gives a list of additional charges with a statement that this list is not exhaustive. The website adds transport, escorting to appointments and hospital visits to this list but also states that this list is not exhaustive and additional charges may be made for other personal items. Kimberley Residential Home DS0000023458.V377626.R01.S.doc Version 5.3 Page 39 Care Quality Commission Care Quality Commission South east Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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