Inspection on 18/02/08 for Kineton Manor

This inspection was carried out on 18th February 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

Kineton Manor 31/10/08

Kineton Manor 01/02/07

Kineton Manor 13/03/06

Kineton Manor 09/08/05

Kineton Manor 15/12/04

Kineton Manor 11/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Kineton Manor Manor Lane Kineton Warwickshire CV35 0JT Lead Inspector Jo Johnson Key Unannounced Inspection 18th February 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kineton Manor DS0000004398.V359740.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. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kineton Manor Address Manor Lane Kineton Warwickshire CV35 0JT 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) 01926 641739 01926 642220 Mr Ken Inglefield Mr Edward Graham O`Rourke Dr Paula Philippa du Rand Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2007 Brief Description of the Service: Kineton Manor is a large converted manor house situated in the village of Kineton and is close to the village amenities. It is set in its own extensive grounds with an outlook onto open fields. The home is surrounded by well kept gardens and a large lawned area. The home is registered to provide personal and nursing care for 43 elderly service users. Ample car parking is available to the rear of the home. The service user accommodation is provided on two floors with 31 single ensuite rooms and 5 ensuite shared rooms. There are two lounges and one dining area. A lift is available to access all floors. The current proprietors Mr Inglefield and Mr O’Rourke have owned the home since 1988. The scale of fees is not included in the service users guide. Fees are discussed at the point of referral and include hairdressing and chiropody. Kineton Manor DS0000004398.V359740.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. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who use the service and their views of the service provided. This process considers the agency’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The manager supplied the commission with an AQAA (Annual Quality Assurance Assessment). Information from this has been used to make judgements about the service, and have been included in this report. Surveys were sent to ten of the people living at the home, ten staff and relatives and visitors. Eight surveys were returned from people living at the home and all were positive about living at the home. Five relative surveys were returned and reflected highly of the quality of the care and service at the home. Seven staff surveys were returned and showed that they do not have any concerns about working at the home. The findings of the surveys are reflected through out the report. This was the home’s first key inspection of 2007/2008. The inspection visit was unannounced (we did not let the home know that we were coming) and took place on 18th February between 9am and 5pm. The inspection involved: • • • Observations of and talking with the people who live at the home and the staff, deputy manager and manager. Observation of working practices and of the interaction between individuals and staff. Four people were identified for close examination by reading their, care plan, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’, where evidence is matched to outcomes for people. A tour of the environment was undertaken, and home records were sampled, including staff training and recruitment, health and safety, and staff rotas. • Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 6 We, the commission would like to thank the people who live at the home, manager, deputy manager and staff for their hospitality and cooperation during the inspection visit. What the service does well: The home has warm and friendly atmosphere. The people living at the home have good relationships with staff and they are relaxed with them. There are good quality and easy to follow assessment and care plans in place. People have good access to local General Practitioners and specialist healthcare when required. The home provides good quality palliative and end of live care. They work closely with the Macmillan liaison nurse. People enjoy the food provided by the home and specialist diets are catered for. Over 50 of the staff have achieved NVQ’s (National Vocational Qualifications) in care. Visitors are made welcome and people are encouraged to maintain contact with family and friends. The home provides both nursing and social work student placements from Coventry University. The home is well managed and people living at the home benefit from this. Comments from relatives’ surveys on ‘What they do well’ included: ‘I find the care home provides an excellent service’. ‘The care staff show genuine concerns for their clients. They brighten up peoples live with their good humour. All the care staff are always very welcoming and well informed.’ ‘The place is welcoming, spotlessly clean. Every member of the team always smiles and greets me and my family’ ‘Give very good care to the people who are looked after at the nursing home. They always make visitors welcome’ ‘They keep my parents safe, clean well fed. The staff treat my parents appropriately and with respect. I feel confident to leave them there’. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 7 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. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 8 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. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 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 Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is good. People’s needs are assessed so that they can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has identified that the service user’s guide needs to be updated to make sure that people have the right information about the home. Information about fees is not currently included in the service user guide as the costs are discussed on an individual basis. The range of fees should be included in the guide so that people know about the charges for the home. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 11 People and visitors spoken with said that either they or their relatives visited the home before making a decision about moving in. Most peoples’ and all the relatives’ surveys showed that they had enough information about the home. One person had moved in a few days before directly from South Africa. They said that their daughter had visited the home before they moved in. They said “she looked at lots of homes and chose this one, she had information about the home…I have been made to feel very welcome”. The manager or deputy undertakes a pre admission assessment before determining whether they can meet someone’s needs. In the case of the person from overseas, information was gathered from the family and the individual before deciding whether they could meet their needs. A fuller assessment, risk assessments and a social history assessment are completed with people as soon as they move in. From this a care plan is developed. Suitable assessments were seen in all four people’s personal care records. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. There is a clear, consistent care planning system in place that provides staff with the information they need to meet individuals’ needs. Risk management strategies are in place to meet the assessed needs of the people living at the home. The principles of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four peoples’ care plans were seen. The care plans were of a good quality and were detailed so that staff are able to meet peoples identified needs. All of the people had tissue viability, nutritional, falls and moving and handling risk assessments and management plans in place. Specific wound management risk assessments and plans were in place for one person with a leg ulcer. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 13 There were monthly reviews for each person they were comprehensive and covered peoples’ identified risks and needs. Both nursing and care staff spoken with said that care plans were clear and easy to follow. They had a good understanding of people’s needs and how to meet them. All the staff surveys showed that they are given up to date information about the needs of the people they care for. The manager told us that she plans to further improve the quality of the plans so that they are more person centred. This means that staff will have a greater understanding of the individuals they care for. Peoples’ preference of gender of staff is identified on their assessment and as there is a mixed staff group, they are able to meet people’s preferences. People spoken with confirmed that their preference of gender of staff is respected. All the relatives’ surveys and visitors spoken with show that the home meets the needs of their relative. Comments from surveys and visitors included ‘on the whole I’m very satisfied with the way in which my relatives needs are met’ and “the staff are caring but very professional we have no concerns”. One person has a lap belt on whilst they are sitting in their chair as a reminder that they are not able to safely stand without assistance. We do not condone the use of any restraint. However, having looked at the record of involvement of: consultant psychiatrists, mental health and social work professionals, the individual and their family. There does not appear to be any other alternative to this that minimises the risk of injuries sustained during falls. This process included a mental capacity act assessment, multidisciplinary meetings and regular professional reviews. There are comprehensive records that reflect the decision-making. All of the people living at the home have had a mental capacity act assessment completed by a student social worker. This is good practice. These assessments should be signed, dated and a date set for review otherwise, it is not clear when the assessment relating to capacity was made and may not be valid. Relatives’ surveys and those spoken with commented on the regular updates that manager arranges for relatives, and spoke highly of a recent session on the mental capacity act and enduring power of attorney. Discussion with people living at the home, relatives, the manager, staff, observation of care plans and daily records showed that people living in the home have access to other health professionals such as GP, dietician, dentist and specialist consultants and chiropodist. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 14 People who need specialist equipment such as a pressure relieving mattress, cushion or hospital type bed have their needs assessed by a nurse and any equipment needed is provided. The medication systems and administration at the home are very well managed. Medication policies and procedures are safe, with medication being stored safely, labelled correctly and administered safely. Only qualified staff administer medication and the deputy manager audits the administration on a regular basis. Any discrepancies are identified on a separate audit record and followed up with the staff involved. Any unused medication is stored in the medication cupboard and is collected by a contractor. All of the medication records and controlled drugs records seen were correct. Staff observed had good relationships with the people living at the home and were patient and encouraging. People with dementia freely approached staff and staff gave them reassurance when needed. Staff respected people’s privacy and dignity, by knocking on their doors and offering personal care discreetly and in private. There are a few shared rooms and they now have curtains that go across the room for privacy. Staff told us that they are always used when providing personal care and that they are an improvement on the old screens. All eight peoples’ surveys show that staff treat them well and that carers listen and act on what they say. People were well groomed and cared for. Relatives and people spoken with said that staff always take care to make sure people are well dressed and their appearance is cared for. Staff spoken with had a good understanding of recognising people as individuals, respecting their privacy and dignity and they were knowledgeable about them as a person. They knew how to balance the need for some structure and routine in the home, in terms of the management of staff and how to meet each person individual preferences. This balance was observed throughout the inspection. The deputy manager has a specialist interest in palliative and end of life care and the home works closely with the Macmillan liaison nurse. The home demonstrates that they provide good palliative care and receive regular referrals from local hospices. They are working towards Macmillan Gold standards in palliative care and use an end of life care plan called the ‘Liverpool Care Pathway’. This is good practice. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 15 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 People living in the home are supported to maintain their independence, contact with important others and lifestyle, which enhances their quality of life. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People spoken with said that their visitors were made to feel welcome whenever they visited. One person said, “my visitors can come whenever they want, they are made to feel welcome and they can join me for lunch either in the dining room or in private”. During the inspection there were many visitors and those spoken with confirmed that they are welcomed and that staff are approachable. Comments included “staff are friendly, welcoming and always smile” and “we come at different times and are always made to feel welcome”. The home supports people in their spiritual needs by the involvement of church ministers of varying denominations or assisting them to attend places of worship in the local community. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 16 There is an activities co-ordinator at the home and there is a regular programme of social activities. There is movement to music, craft activities, bingo, book club, shop, twice monthly day trips and hairdressing. There is a PAT (Pets as Therapy) dog that visits on a regular basis. The manager told us that they are planning to complete life history books with people. This is in addition to the social history and personal interests information they already have and this will improve staffs understanding of them as a person. People spoken with and observed got up and spent their time how and where they chose. A concern had been raised with the commission by a relative about some of the routines at the home and in particular about the people’s choices about having a rest after lunch. We observed that staff asked people if they would like a rest on their bed after lunch and if people chose not to do this, their choice was respected. One person was supported to lie on their bed but then got up a few minutes later. Their wishes were respected and staff supported them to go to a lounge of their choosing. From discussions with staff and the manager and observation, there is some planned structure and routines in place at the home. However, these do not impinge on people’s choice as to how they wish to live their lives. This is the manager’s style of management and ways of ensuring peoples’ needs are met. At no time during the inspection did this have a negative impact on the outcomes for people at the home. The kitchen was awarded a ‘Gold’ award in October 2007 by Environmental Health Officers. The kitchen was well stocked with a variety of fresh and long-life foodstuffs. The cook was knowledgeable about the diets of the people at the home and soft and diabetic diets are provided. Menus are held in the kitchen and the daily menu is displayed on the door leading into the kitchen. There is also a photographic menu so that people with dementia or who communicate differently can point to their choice. This is good practice. We joined one person and their relative for lunch in the main dining room. The atmosphere was relaxed and there were enough staff to serve the meal at a suitable pace. All meals were served hot. People said they enjoy the meals and stated that they are always offered choices. One person said, “meals are good and we have drinks whenever we want” and “the food is good and I’ve been given a choice”. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 17 Relatives of a person, who is cared for in bed, said that staff are vigilant about making sure that their relative is sat up for drinks and meals. They said that they sometimes assist the individual with their meals and staff always give them clear guidance on how to safely do this. All but one member of staff were observed to sit with people and assist them to eat where needed. Staff spoke to people through out the meal about what they were eating and offering choices. Staff should always sit down with people rather than stand over them to assist them with eating. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 18 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): 16,17,18 Quality in this outcome area is good. Complaints procedures make sure that peoples, relatives and representatives concerns and complaints are listened to and acted upon. A staff team who have a good knowledge of how to respond to any suspicion of abuse and to keep people safe from harm support the people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy is displayed in the home and is in the service users guide. From discussion with the manager and information provided in the AQAA, there have been two complaints that have been investigated and resolved in the last 12 months. The records were seen for these complaints and they included the outcome. The commission has received two concerns since the last inspection. One was from a relative concerned about the routines at the home and another concerned about the safe recruitment of staff, large turnover of staff and Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 19 medication management. Both of these concerns were looked at during the inspection and the findings reflected throughout the report. People spoken with and surveys showed that they all knew whom they would talk to if they were unhappy or needed to complain. The person who had moved in two days before said, “I would talk to staff if I was unhappy but I have nothing to complain about they have made me feel very welcome”. Relatives spoken with and surveys show that they know how to make a complaint about the home. Comments included ‘matron is very approachable and always has time for my relative and for me’ and one relative said, “I don’t have any concerns, I would talk to the manager if I had”. Since the last inspection staff have attended training in the Protection of Vulnerable Adults (POVA) so that they are aware of the different ways vulnerable people are at risk of abuse, and would know how to respond. Staff spoken with had a good understanding of how to recognise and report any allegations of abuse. People with dementia were observed to be very relaxed with staff, gave them many smiles and were happy to approach them. This may indicate that they feel safe. There was an incident the previous week during the night when an intruder was found in the kitchen of the home. From discussion with the deputy and manager the kitchen door is normally locked but the staff had forgotten to lock the door that evening. They have ensured that all staff are being extra vigilant following the incident. This incident was not reported to the police. Any incidents where there are intruders or any break in to the home must be reported to the police and to the commission. This is to make sure that people living at the home are safeguarded from intruders. There have been no allegations of abuse at the home. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 20 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): 19,26 Quality in this outcome area is good. The home is maintained and furnished so that people live or stay in a homely, clean, comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides a relaxed, cosy and friendly atmosphere. Since the last inspection there has been a new conservatory added to the small lounge, the large lounge has been refurbished, the main corridors have been redecorated and re-carpeted and the laundry has been refurbished. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 21 Communal areas of the home are spacious, comfortable, light and airy. Armchairs are comfortable and clean. Carpets and the decoration are generally in good condition. The surveys from people living at the home show that the home is fresh and clean. One person spoken with said “I have a lovely room with my things in and everywhere is very comfortable” Relatives spoken with said, “it’s homely here, it never smells and is always spotlessly clean. Personal rooms seen were nicely decorated and appropriately furnished. People are encouraged to bring their own belongings, personal items, and small pieces of furniture into the home. All of the rooms have ensuite shower, hand basin and toilet. The home employs maintenance and gardening personnel. The home is well maintained, and the gardens are well kept and provide good additional outside space for people to use. From information provided in the AQAA and records seen during the inspection, there are good monitoring systems in place to make sure that the environment is safely maintained and managed. There is regular testing of water temperatures, servicing of equipment and systems. During the inspection, there no doors propped open. A majority of the doors in the home have automatic fire closures fitted. A tour of the kitchen and laundry found these to be tidy and clean. Washing machines are provided with sluicing programmes, and separate hand washing facilities are provided in both areas for staff, to minimise the risk of cross infection. Systems are in place to reduce the risk of infection. Disposable gloves, aprons and hand scrub are available and used by staff when handling soiled linen and when supporting people with personal care. Staff were observed wearing disposable plastic aprons when serving food and when entering the kitchen. Ramps provided safe and easy access to the gardens, which were attractive, spacious and well managed. The home has two pet cats and a few chickens in the garden. One person was seen to go out in the garden independently. They said “ I like to go out into the garden every day to see the chickens if I can”. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 22 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): 27,28,29,30 Quality in this outcome area is good. The people living in the home are protected by robust recruitment practices and supported by a skilled, competent and well managed staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of inspection there were 41 people living at the home. Staff • • • • rotas seen show that staffing was as follows: 07:30 – 4pm- 2 Registered Nurses and 10 care staff plus 08:00-5pm - 1 Registered Nurse 3.15pm – 9:30pm- 1 Registered Nurses and 6 care staff 9pm – 8am-1 Registered Nurse and 3 care staff In addition, there were sufficient laundry, catering, cleaning and maintenance staff to ensure that nursing and care staff did not spend time undertaking noncaring tasks. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 23 The registered manager is also a general nurse but was not included in the number of nurses on duty. During the inspection, the staffing levels were adequate to meet the needs of people living at the home. From discussion with the deputy and manager the staff team at the home has stabilised since the last inspection. There has been some turnover of staff but not as high as previous years. This was confirmed through discussions with staff, people who live at the home and relatives. There is a core of both qualified and care staff who have worked at the home for many years. Agency staff are not used at the home. Since the last inspection, the home has employed an English teacher and overseas staff have English lessons once a week. People, staff spoken with, and surveys show that there are enough staff to meet people’s needs and that staff are available when people want them. Four staff files were seen including the most recently recruited staff. The files were well organised. All files included evidence of CRB (Criminal Records Bureau) checks and PoVA (Protection of Vulnerable Adults) checks. For one person whose CRB check had not yet been returned they were working alongside another member of staff. The application form has been reviewed and updated to request a full adult life or working history. All seven staff surveys and staff spoken with show that that checks such as CRB and references were carried out before they started work. The staff files were well-organised and included supervision and training records. From the AQAA (Annual Quality Assurance Assessment) completed by the manager, the training programme and discussions with staff there is a comprehensive training programme in place that focuses on mandatory training and the specific needs of the people living at the home. Staff spoken with and surveys show that they are given training that is relevant to their role. There is an active NVQ programme and over 50 of staff have achieved level 2 or above. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 24 The induction programme seen and staff spoken with and surveys show that that they had an induction that covered everything the needed to know to do the job. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 25 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. People benefit from living in a well run home. They are able to express their views of the service provision and know that their views will be listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is an experienced qualified nurse with a PhD in nursing and has been in post as a manager at Kineton Manor since November 2003. She is had completed the Registered Manager Award (RMA) and Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 26 participates in periodic training to update her knowledge, skills and competence. The manager lives on site and told us that this means that she is able to monitor the service throughout the day and night. The manager provides both nursing and social work placements for Coventry University. These placements clearly benefit the people living at the home. For example, the recent work on the mental capacity act, staff training and relatives information session has benefited the people living at the home as they have all had their capacity assessed in line with the new act. There were clear lines of responsibility and accountability within the home and as well as the manager the senior team includes deputy manager, senior nurses, nurses and senior carers. Each senior team member has key areas of responsibility and is accountable to the manager. During the visit staff appeared confident in their roles, the home was relaxed and people appeared at ease and comfortable. Staff spoken with commented positively about the style of management and leadership from the manager, their job role and the people living at the home. The management approach of the home creates an open, positive and inclusive atmosphere and the registered manager communicated a clear sense of direction and leadership. The manager has developed a comprehensive quality assurance system. From information given in the AQAA (Annual Quality Assurance Assessment) and what the manager told us, this system includes regular audits of each area of the home, surveys to people living at the home, relatives and a full annual review. The manager showed us the annual review completed in December 2007 and the new objectives and plan for 2008. The standard of the review and plan were of a good quality. The owners of the home visit the home on a regular basis and complete monitoring records as required by the regulations. Information provided before the inspection, by the manager in the AQAA (Annual Quality Assurance Assessment) shows that relevant Health and Safety checks and maintenance are being carried out at the home. A number of Health and Safety records were checked, including the fire safety log. The fire system is tested on a weekly basis. These records showed that health and safety matters are well managed. Staff spoken with said they attended fire drills and have been trained in health and safety procedures. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 27 Staff spoken with and records seen show that staff are supervised and have had an annual appraisal. Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 28 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 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 4 x 3 3 x 3 Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? No Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 30 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 OP18 Regulation 13(6) 37(f) Requirement Any incidents where there are intruders or any break in to the home must be reported to the police and to the commission. This is to make sure that people living at the home are safeguarded from intruders. Timescale for action 01/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP2 OP7 Good Practice Recommendations The range of fees should be included in the guide so that people know about the charges for the home. Mental Capacity Act assessments should be signed, dated and a date set for review otherwise, it is not clear when the assessment relating to capacity was made and may not be valid. Staff should always sit down with people rather than stand over them to assist them with eating. This is so that people have a relaxed enjoyable meal at their own pace. 3 OP15 Kineton Manor DS0000004398.V359740.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. 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