Inspection on 09/09/08 for Kimberley Residential Home

This inspection was carried out on 9th September 2008.

CSCI found this care home to be providing an Good service.

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 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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Kimberley Residential Home 40 Mickleburgh Hill Herne Bay Kent CT6 6DT Lead Inspector Chris Woolf Unannounced Inspection 09:35 9 September 2008 th 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.V369183.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.V369183.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 home@kimberley-care.com C&P Limited Mrs Amanda Jane May Care Home 36 Category(ies) of Dementia (0) registration, with number of places Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Dementia (DE). The maximum number of service users to be accommodated is 36. Date of last inspection 18th September 2006 Brief Description of the Service: Kimberley Residential Home is a care home currently providing personal care and accommodation for 36 older people with dementia. 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, which gives access to all areas. There are 26 single rooms, 7 with en-suite facilities, 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 at the time of the visit range from £386.81 to £485.00. 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. The e-mail address of the home is admin@kimberleycare.com. The web site address is www.kimberley-care.com Kimberley Residential Home DS0000023458.V369183.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 2 star. This means the people who use this service experience good quality outcomes. Key Lines of Regulatory Assessment (KLORA) have informed the judgements made based on records viewed, observations made and written and verbal responses received. KLORA are guidelines that enable The Commission for Social Care Inspection (CSCI) to make an informed decision about each outcome area. This report is based on information gained from an Annual Quality Assurance Assessment (AQAA) completed by the home, and two site visits to the home the first lasting 6 hours and 35 minutes, and the second lasting 1 hour and 40 minutes The first site visit was unannounced, this means that neither the clients nor the staff knew that we (the Commission) were intending to visit. On the day of the first site visit the Registered Manager was on annual leave and Mr. Kevin Post, one of the providers, and a senior care assistant made themselves available to help us. During the first day of the site visit we spoke with a number of clients, three visitors, staff on duty, and the provider. We looked at records including care plans, assessments, activity records, menus, staff rota, staff training matrix, and medication records. We had a tour of the building. Observations were undertaken of the interactions between staff and clients, activities taking place during the morning, the lunchtime meal, and the administration of medication. The second day of the site visit was arranged to enable us to look at staff recruitment files, which were not available whilst the Registered Manager was on holiday. The people who use this service are normally referred to as either clients or residents. For ease of reading they are referred to throughout this report as clients. Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The statement of purpose and service user guide has been amended to include views of the clients. Medication practices have been improved The clients activities programme has improved and there is now a dedicated activities coordinator New televisions have been purchased for the communal areas The home has joined NAPPA (the National Association for the Providers of Activities for Older People). Monitoring now takes place when clients are not eating or drinking well The homes whistle blowing policy has been reviewed The home has been extended and 7 new en-suite rooms have been provided. All first floor rooms are now accessible by lift and corridor rather than stairs The garden has been redesigned. The new garden includes sensory elements for sight, sound, smell, touch, and taste. Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kimberley Residential Home DS0000023458.V369183.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.V369183.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, & 4. Standard 6 is not applicable in this home Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients and their representatives have the information needed to choose a home that will meet their needs EVIDENCE: Information for prospective clients and their representatives is provided in the form of a Statement of Purpose/Service User Guide. An improvement made during the last year has been to update this document to incorporate the views of the clients. Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 10 The home has comprehensive assessment procedures. The manager and/or one of the proprietors visit each prospective client, wherever they are currently living, to carry out the first part of the assessment. Following the decision to admit someone to the home the second part of the assessment is undertaken to establish some life history, values and beliefs, routines, and likes and dislikes. Where a client is under the care management scheme a copy of the Councils assessment is also obtained. Visitors spoken to on the day of the site visit all confirmed that pre-admission assessments took place. Their comments included, Kevin (proprietor) and Amanda (manager) visited her at the home she was in, Kevin and Amanda did at pre-assessment in the hospital, and They came out a couple of times to see her before agreeing for her to move in. This is a home specifically for people suffering from dementia. Records seen show that the majority of staff have had specific training in dementia and challenging behaviour. Comments from visitors included, I know Mandy (the manager) understands Dementia. This home does not offer the facility of intermediate care. Intermediate care is a specialised service with dedicated accommodation, staff, and equipment, to deliver intense rehabilitation of clients to help them to return to their own homes. Kimberley Residential Home DS0000023458.V369183.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that clients receive is based on their individual needs. The principles of respect, dignity, and privacy are put into practice. EVIDENCE: An individualised plan of care covering physical and mental health, social, and cultural needs is produced for each client. The care plan, which is based on the pre-admission assessment, is regularly reviewed and updated. Care plans include This is my life, a variety of assessments including, confusion, dependency, self help skills, safe environment, dressing and undressing, Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 12 continence, and social activities, and a variety of risk assessment including moving and handling, nutrition, and where appropriate, bed rails. The clients health and personal care needs are met by the staff, supported by a multi-disciplinary community health care team. Evidence was seen in the care plans of contact with doctors, district nurses, optician, and visits to the hospital. GP Surgeries review their clients every 6 months. The homes AQAA says, We have a quarterly clinic held at the Home by the Consultant Psychiatrist and his CPN who have responsibility for their patients in our care. Any incidence of pressure sores is reported to the district nurses who visit to give treatment and advice and who also provide appropriate equipment. Nutritional screening is undertaken for all clients but it was witnessed that some have been unable to be weighed regularly and provider should consider ways of addressing this. Visitor comments included, I was recommended to the home by a doctor, They are very caring here, My wife broke her hip but she has got over it, and Amanda got the doctor in last week to see him, I was impressed. Minutes of a meeting confirmed that health care professionals had no concerns and had not had any issues with the care in the home. The home has good procedures for the receipt, recording, administration, and disposal of medication. The Boots monitored dosage system is in use in the home. All staff who administer medication have received training. Staff said, I have had medication training, and No I have not medication training I dont deal with medication, thats a seniors job. Medication administration witnessed was handled sensitively. The manager audits medication on a regular basis. Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients are able to make choices about their life style. Cultural and recreational activities meet individuals expectations. Menu choice would be enhanced if there were a dedicated person to prepare the evening meal. EVIDENCE: The activities on offer for clients have improved since the last inspection. The AQAA says, The home has recently joined NAPA (the National Association for Providers of Activities for Older People) and intend to incorporate some fresh ideas into our activities programme. Clients interests and preferences are sought and are recorded in their care plan. The home currently employs an activities organiser. On the day of the site visit a number of clients were witnessed enjoying playing cards and dominoes, looking at magazines, and colouring with the activities coordinator and two carers. A visitor commented, Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 14 She wont do activities, she has never liked that sort of thing. Staff comments included, They have enough activities, They could have a bit more in the way of activities, The activities lady comes in daily and the clients enjoy having time out of their choice. Its good for their communication, They do different things for the seasons and festivals, and We dont have much time for 1:1s, although we can occasionally manage them. Another improvement in the last year has been the purchase of 3 widescreen televisions with built in freeview for the communal areas of the home, allowing access to a greater variety of programmes. The homes AQAA says, Following the design and landscaping of the garden there is more use of outdoor facilities and many clients grew sunflowers last summer as part of their activity. A visiting singer entertains the clients every two weeks. A staff member said, There is a singsong man who comes in, they enjoy that and have a boogy. A Pets as Therapy dog had been visiting the home weekly. The home is currently waiting for a new visiting dog and owner to be allocated to them. Clients cultural needs are included in their assessment. The current clients are all of Christian faith and a Church of England service with communion offered takes place monthly, and a Catholic priest also visits regularly. Visitors spoken to on the day of the inspection confirmed that they are made welcome and are able to visit at times suitable to them and the client. They said, I come in every week, I come in every day, I like to help xxx with her meal, and I come in at different times of the day. The homes AQAA says Clients who are able to express a choice are able to make choices with regard to their day-to-day lives. A visitor commented, She can smoke in the conservatory, the staff look after her cigarettes and give her one when she asks. Staff comments about choices on the day of the visit included, Today they have a choice of beans or spaghetti with tea, or which type of sandwich they would like, They can choose where to sit, and whether they want to wander, although we always keep an eye on them, They dont really get enough choices, Most of them are up by 8 oclock. The night staff get them up, but a few prefer to stay in a bit longer, and Going to bed is normally at the times that the families have suggested they are used to. The AQAA says, One of the proprietors and the Manager have completed training in the Mental Capacity Act to ensure increased awareness of a clients right to their own decision making and the various options if they appear to be incapable of doing so, including advocacy Food served to clients is home cooked. The AQAA says, A four weekly seasonal menu is offered with likes and dislikes being established in advance. The menu continues to state the main cooked meal of the day as our experience has shown that different meals delivered to the same table can cause discord. That said, where a client clearly needs to be encouraged to eat, an alternative is prepared if the first alternative did not prove popular. On the Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 15 day of the site visit 2 clients were observed taking advantage of an alternative choice to the main meal. Specialised meals are catered for as needed. If the home is concerned that a client is not eating or drinking well food and fluid intake charts are maintained and relevant health care professionals are informed. Records are kept of all of the meals provided. The tea menu is a little restrictive as it relies on the cook doing the preparation before leaving and the care staff completing and serving the meal. Clients would benefit from having a dedicated person to prepare the tea time meal as this would allow for a wider range of menu to be offered. A recommendation has been made to the management regarding this. Visitor comments included, I feed lunch to her, she is eating much better than she was and is even eating things that she never liked at home, and No problems with the kitchens. Staff said, The morning cook prepares the tea or sandwiches, then a carer needs to come off the floor to finish it off, They have homemade cakes, Its O.K., Tea has to be something easy which means the clients get less choice, Its the type of food they are used to, Its quite nice actually, I have lunch myself if I am on a long day, They have a choice of meals with lots of alternatives available, and Some prefer their hot meal in the evenings Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clients and their representatives are able to express their concerns and have access to a robust, effective complaints procedure. More robust recruitment procedures are required to ensure clients are protected from abuse. EVIDENCE: The home has an accessible complaints procedure and a copy is available in the Statement of Purpose and Service User Guide in the hallway. There have been 2 complaints recorded in the last 12 months. Staff spoken to on the day of the site visit all confirmed they would know how to deal with a complaint. Visitors commented, I have got nothing but praise for them, People who have spoken to me have never heard anything bad about the home, They are very good here, I have not complainted but I spoke to Kevin about something and he has taken it on board, and I would be very quick to complain if I felt it was necessary. Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 17 Clients are generally protected from abuse. The home has an adult protection policy and a whistle blowing policy. The whistle blowing policy has recently been updated. All staff spoken to confirmed that they would know what to do if they suspected that a client had been abused. Comments included, If I through anything was wrong I would report it, and I learned about it in adult protection training. There is currently an adult protection alert open on the home, the management have cooperated fully with the investigation and we have been informed that the alert will shortly be closed and no further action is necessary. Some staff have been employed prior to the home receiving a satisfactory check of the protection of vulnerable adults register. This was discussed during the site visit and has been the historical way of working. The provider and manager are now fully aware of the situation and in future no new member of staff will be employed until a satisfactory check of the Protection of Vulnerable Adults register has been received. A requirement has been made about this under the section on staffing. The staff training matrix confirms that the majority of staff have now undertaken Adult Protection training, a staff member said, I did the training last week. The management are aware of their responsibilities in reporting to the Protection of Vulnerable Adults Register. Kimberley Residential Home DS0000023458.V369183.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Clients live in a home that is safe and comfortable. Planned maintenance will enhance the environment for the benefit of the clients. EVIDENCE: Since the last inspection the home has increased its registration with the addition of 7 new en-suite bedrooms. The home now comprises of 4 houses linked together. As part of the recent works improvements have been made to ensure that all first floor rooms can now be accessed via lift and corridor, Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 19 rather than stairs. There are some areas of the home where the décor needs attention and the provider is prioritising the work to be done against budget available. It is suggested that once the provider has done this he should produce a written development plan showing the areas concerned and the proposed dates of completion of work. Areas needing attention include the carpet in the lounge, which needs to be thoroughly cleaned or replaced. The laundry area needs attention. There are some areas where wallpaper has been pulled off the walls. Since the last inspection the garden has been redesigned. The AQAA says, Plants were chosen for their sensorial nature: other than the obvious sight of the garden, sound was considered with bamboo, stipa gigantea, miscanthus sinensis zebrinus and others. Smell from lavendar, roses, nepeta and the herbs; touch from stachys, lavender, bamboo and rosemary; and taste: sage, thyme and rosemary. A visitor commented, Its nice to have a garden. Shared facilities in the home include a large divided lounge and dining area, a smaller lounge/dining room, and a conservatory/smoking room. A new consulting room has also been provided between the entrance and the dining room. A variety of activities are held in the larger dining room each morning. Clients bedrooms are personalised to meet their choices. Where clients share a bedroom appropriate screening is available to ensure they can maintain their privacy. There is a lockable storage space available for all clients who would like this facility. The home is kept clean. Visitors said, Its very clean, look at the chairs, there is nothing wrong with them, and The cleanliness is very good. Staff comments included, Yes, its clean, and Its clean most of the time. There are a couple of isolated areas where an unpleasant odour can be detected and the manager has been advised that she needs to address the management of this problem. A visitor commented, Sometimes the bedroom is a bit smelly. The provider is currently investigating ways of improving the laundry and its facilities. Currently, liquid soap and paper hand towels is not available in all appropriate areas but the provider has already identified this shortfall and is making arrangements to address it. Gloves and aprons are available for staff and located in accessible areas around the home. Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improved recruitment procedures and up to date staff training are needed to fully protect the clients EVIDENCE: Comments received from staff about the number of staff on duty varied and included, We have enough on duty unless someone is sick then we get agency to cover, Generally there are not enough staff on duty, Normally we have a senior and 3 carers on duty in the day and 4 carers at night, Its only now and again that we only have 3 on duty, There are not enough staff on, they dont have the time to do things. A recommendation has been made to the management that the number of staff on duty be kept under review to ensure that there are always sufficient staff on duty to meet the needs of the clients. A further recommendation was made to the management in the outcome area of Daily Life, regarding the employment of a dedicated tea time cook. Currently there are only 6 staff with NVQ (National Vocational Training) Level 2. However a further 3 are undertaking Level 2 and one is doing Level 3. Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 21 Once they have completed the training there will be 50 of staff appropriately trained. Staff said, I have just finished my NVQ 2, I am doing my NVQ 3 at the moment, and I am ½ way through my Level 2. The homes recruitment procedures need to be tightened up. The home obtains 2 written references before employing new staff. The application form asks for a full employment history. New staff work in the home under supervision until a satisfactory Criminal Records Bureau Enhanced Disclosure is received. However, the home does not wait to receive a satisfactory check of the Protection of Vulnerable Adults register before the member of staff commences work and this could put clients at risk. A requirement has been made regarding this. All new staff employed in the home have an induction based on the Smkills for Care common induction standards. A member of staff said, I do an induction into the home with new staff. At the time of the site visit training in the mandatory subjects was not totally up to date, although a number of courses had been planned. A requirement has been made regarding this. The AQAA says, In collaboration with SECAS (South East Care Advice Service) we have undertaken a skills audit of our care staff in order to produce an overall workforce development plan as well as personal development plans for each member of staff. This has allowed us access to training funding. Staff comments about training included, We go on separate training courses, All the night staff are properly trained, and I am doing my Food hygiene next week. In addition to the mandatory training evidence was seen of training in Challenging Behaviour, and Nutrition. Visitors comments about the staff included, All the staff are nice to talk to, They are very nice girls here, All the staff are very helpful, xxx is very sweet, There have been a few staff changes, they have lost 2 good carers but they have agency staff to cover, and The young girls are very good, very caring. Staff said, I like working here, it’s a lovely job, I like working here, as long as the clients are happy its good, I love it here, and The carers are fantastic. Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect and has effective quality assurance systems. The health, safety and welfare of clients and staff will be fully protected once mandatory training is up to date. EVIDENCE: The Registered Manager is skilled, competent, and experienced to run the home. Staff reported, I get support from the manager, The manager is very supportive. We get on well and if I have a problem she is always there Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 23 for me, I sometimes get support from the manager, and The manager is supportive, she is always available. Visitors commented, Mandy is very good, if I go to her she does what I say, I know Mandy understands Dementia, and The person who recommended the home to me told me that Mandy is the best in Herne Bay. Staff confirmed that the manager often works on the floor when they are short staffed. It is important that the manager retains sufficient supernumerary hours to allow management tasks to be undertaken and kept up to date. There are clear lines of accountability within the home, with Senior Care Assistants supporting the manager in the day to day running of the service. In addition one of the providers has an office in the home and is there most days. Visitors comments about the provider included, Kevin is very good, you can talk to him. If you ask for something he will see it is done, and I was very impressed with Kevins professionalism. Staff said, Yes, the provider is supportive, He gives support, and I dont see much of Kevin but I am able to speak to him when I want to. The home has developed its own Quality Assurance systems. The AQAA says, The home sends questionnaires to clients representatives to seek their views, organises staff meetings and acts upon points raised. We feel that we run the Home in the best interests of the clients. The next batch of Quality Assurance questionnaires are due to be circulated to clients relatives in October 2008. In addition to circulating questionnaires to relatives, there is always a supply of questionnaires in the hallway for any visitor to pick up and complete. The home has organised for an independent annual quality assurance inspection by Kent Care Homes to take place in October. Regular audits are undertaken of clients bedrooms, and the overall building. The home does not hold any monies for clients. All transactions undertaken on behalf of clients are invoiced to their relative or representative. The health, safety and welfare of staff and clients is generally protected. However, a requirement about mandatory training has been made under the outcome area of staffing. All safety records and accident records viewed are up to date. Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 24 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 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 X X X 3 X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 25 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 OP29 Regulation 19 (1) (b) Requirement The manager must ensure that no new member of staff is employed until a satisfactory check of the Protection of Vulnerable Adults Register has been received The manager must ensure that staff training in the mandatory subjects, and in adult protection, and dementia is kept up to date and valid. Timescale for action 30/09/08 2. OP30 18 (c) (i) 31/12/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kimberley Residential Home DS0000023458.V369183.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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