Inspection on 27/01/06 for Kimblesworth Care Home

This inspection was carried out on 27th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kimblesworth Care Home 18/11/08

Kimblesworth Care Home 24/01/07

Kimblesworth Care Home 29/07/05

Kimblesworth Care Home 08/12/04

Kimblesworth Care Home 21/07/04

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

CARE HOMES FOR OLDER PEOPLE Kimblesworth Care Home Kimblesworth Care Home Elm Crescent Kimblesworth Chester le Street County Durham DH2 3QJ Lead Inspector Mrs Sue Lowther Unannounced Inspection 09:30 27 January 2006 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 Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 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. Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kimblesworth Care Home Address Kimblesworth Care Home Elm Crescent Kimblesworth Chester le Street County Durham DH2 3QJ 0191 3712259 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) Mental Health C.A.R.E. Paul Satterthwaite Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (20) Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Manager Paul Satterthwaite should attain (by 2005) a qualification at level 4 NVQ in Management or equivalent. Date of last inspection Brief Description of the Service: Kimblesworth Care Home is a converted school situated in a small village on the outskirts of Durham. The home provides 24- hour personal care (with nursing) for twenty service users with mental health needs who are over sixtyfive years of age. Accommodation is provided on two levels, with a choice of lounges and dining room and other quiet areas for use by the service users. The staff team within the home comprises registered nurses, care staff, domestic staff and kitchen staff. The company have a maintenance team who visit the home on a regular basis. Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4 hours, on 27th January 2006. In line with current CSCI policy on ‘Proportionality’, the inspection focused upon a number of key standard outcomes for service users. The key standard outcomes not inspected on this occasion were assessed during the last inspection of the home. The inspector looked around the building and a number of records were examined. 6 service users, the manager and 3 members of staff were spoken to. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these outcomes / standards were assessed on this occasion. The key standards were assessed during the course of the last inspection. EVIDENCE: N/A Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 A computer care planning system has been introduced and is not yet fully developed. The care plans examined did not fully demonstrate that the home is meeting all of the service users healthcare needs. The medication systems within the home are being adhered to and service users are protected by a safe system that is properly operated by staff. Staff treat service users in a manner that respects their privacy and dignity. EVIDENCE: Service user plans are computerised, however the deputy manager said that all of the service users can access these at any time and can have a paper copy if they wish. Service users spoken to confirmed this. Although assessment information covers widespread areas of need, they do not always inform the care plan. One service user had lost a significant amount of weight and there was no care plan to demonstrate whether this was intentional or whether it had been considered within the evaluation process. Care plans demonstrate that health and social care staff are involved with the care of the residents and outline where Doctors, District Nurses and Community Psychiatric Nurses visit the home. Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 9 Drug storage is secure and clinical areas are well organised and tidy. Medication Administration Recording (MAR) charts are well kept. Controlled drugs are appropriately stored and stock balances are kept correctly. Service users confirmed that staff treat them with respect and that their dignity is maintained. Service users are addressed by the name that they prefer and the inspector saw that staff knock on bedroom doors and wait until they are invited in. Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 The home operates in a way that enables service users to engage in purposeful social and recreational activities. EVIDENCE: There was good practice relating to the promotion of independence and social contact with people outside the home. Service users said that they are able to see their relatives and friends at any time and that staff sometimes help them to go out to see their friends. The home encourages service users to use community facilities such as the local shops, visits to the hairdresser and GP appointments. This provides the opportunity for individual service users to maintain a level of independence within their capabilities. An activities organiser is employed at the home and there was a varied range of activities offered. Service users were able choose whether or not they wish to be involved. Service users who had been on holiday in the late autumn spoke about how much they had enjoyed this and the inspector saw photographs of this event. Without exception, service users said that the food was good and that there is a choice available. Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 11 The dining area was pleasantly furnished and provides a spacious setting for service users. The tables were set with appropriate cutlery, condiments and choice of drink. A number of service users said that they could choose to have their meals in their own bedroom and that if they wish to do so, staff would make the necessary arrangements for this. Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these outcomes / standards were assessed on this occasion. The key standards were assessed during the course of the last inspection. EVIDENCE: N/A Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these outcomes / standards were assessed on this occasion. The key standards were assessed during the course of the last inspection. However it was noted that the recommendation in the last report with regard to the flooring in toilet and bathrooms has been actioned. An audit has been undertaken and some flooring has already been replaced and more are planned. EVIDENCE: N/A Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these outcomes / standards were assessed on this occasion. The key standards were assessed during the course of the last inspection. EVIDENCE: N/A Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, & 38. The manager provides good leadership and direction for the staff. This ensures that the service runs in the best interests of service users, promoting and safeguarding their rights. EVIDENCE: The manager is a qualified nurse and has commenced an appropriate management course. The staff who were spoken with indicated that the manager runs the home for the benefit of the service and has a positive relationship with staff. Similar comments were also made by a number of service users. The company have put in a number of quality assurance systems, which are regularly reviewed. Service users’ views are obtained through regular contact and an ‘open door policy’. Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 16 Service users have individual bank accounts. Small amounts of personal allowances are kept. These were examined and found to be in order. A member of staff and the service user sign for monies withdrawn from the personal allowances. If the service user is unable to do so then two members of staff will sign. The company have detailed health and safety policies and copies of these were available for inspection. Staff spoken with confirmed that they have received health and safety training with regard to moving and handling and fire safety. Servicing records were examined and there was evidence of regular servicing of fire equipment and gas and electrical appliances being carried out by contracted companies. All of the servicing records that were examined were up to date. Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 X 3 3 Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 14, 15, 17 & Sche 2 17(2) & Sch4(11) Requirement A care plan must be available for all of the needs identified in the assessment and evaluation process. Records of the food provided for service users must be kept in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual service users. The manager must complete a management-training course at NVQ level 4 or equivalent. Timescale for action 31/03/06 2 OP15 31/03/06 3 OP31 8&9 30/09/07 Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 19 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 OP21 Good Practice Recommendations The replacement of flooring in the bathrooms and toilet areas should continue. Kimblesworth Care Home DS0000043604.V249181.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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