Inspection on 04/08/09 for Kingsbury House

This inspection was carried out on 4th August 2009.

CQC found this care home to be providing an Adequate 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

Kingsbury House 27/11/08

Kingsbury House 24/07/08

Kingsbury House 04/03/08

Kingsbury House 19/12/06

Kingsbury House 03/11/05

Kingsbury House 29/07/05

Kingsbury House 09/02/05

Kingsbury House 27/09/04

Kingsbury House 18/02/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Kingsbury House 61-62 Percy Park Tynemouth North Shields Tyne & Wear NE30 4JX Lead Inspector Glynis Gaffney Key Unannounced Inspection 04 August 2009 14:00 DS0000000371.V377216.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsbury House Address 61-62 Percy Park Tynemouth North Shields Tyne & Wear NE30 4JX 0191 2575121 0191 257 5121 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) Mrs Pamela Craig Dawson Manager post vacant Care Home 30 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (21) of places Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th July 2008 Brief Description of the Service: Kingsbury House consists of three converted terraced houses which have been adapted to provide care and support for 30 older people, some of whom may have dementia care needs. Nursing care is not provided. The home is close to the Tynemouth seafront and sea views can be enjoyed from some bedrooms. The home has a large lounge, a smaller quiet lounge and a spacious dining room. The home is located close to local transport links and street parking is available. Bedrooms are situated on the ground, first and second floor levels. Single room accommodation is offered throughout. En-suite facilities are available in two bedrooms. Access to all floors is by way of a passenger lift. The weekly fee charged ranges from £379 to £410. A service user guide and copies of Care Quality Commission (CQC) inspection reports are available to help people decide whether the home can meet their needs. Kingsbury House DS0000000371.V377216.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 1 star. This means that the people who use this service experience adequate quality outcomes. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. How the inspection was carried out: Before the visit: We looked at: • • • • Information we have received since the last key inspection visit on the 27 November 2008; How the service dealt with any complaints and concerns since the last visit; Any changes to how the home is run; The manager’s view of how well they care for people. The views of people using the service, their relatives and staff. . The Visit: An unannounced visit was made on the 04 August 2009. During the inspection we: • • • • • • Talked with the provider and manager; Looked at information about the people who use the service and how well their needs are met; Looked at other records which must be kept; Checked that staff have the knowledge, skills and training to meet the needs of the people they care for; Looked around the building to make sure it was clean, safe and comfortable; Checked what improvements had been made since the last visit. We told the provider and manager what we found. Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 6 What the service does well: Service users are encouraged to visit Kingsbury House before making a decision to accept a placement at the home. A range of care plans have been devised for each person. Those looked at address people’s needs in a range of areas such as mobility, nutrition and personal care. Monthly reviews are carried out. This will help staff to be clear about the actions they must take to meet people’s needs. A range of preventative healthcare risk assessments have been completed. This will help to ensure that people receive the healthcare support they require. The home employs an activities co-ordinator who provides a range of in-house activities such as gentle armchair exercise sessions and musical bingo. A full time maintenance worker is also employed. The home is kept clean, hygienic and tidy. Rotas are completed in advance so that staff can see what shifts they will be working. This helps the home to plan cover for staff training and holidays, as well as any sickness that may occur. Staff are provided with a staff handbook and a Code of Practice. The provider employs an independent company to provide them with personnel and employment law advice. All staff have completed the required mandatory training and have obtained a recognised qualification in social care. What has improved since the last inspection? Arrangements to refurbish the home have been put refurbishment is due to take place over the next six months. in place. The The home’s policies and procedures have been reviewed during the past 12 months. Improvements have been made to the way in medicines are handled within the home. For example, a Controlled Drugs (CD) cabinet has been installed since the last inspection. The system for managing CDs is now more robust. The home’s medication policy has been updated. Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 7 Arrangements have been put in place to ensure that staff receive regular work practice supervision. This will help to ensure that people are being cared for by staff that are properly supported and supervised. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Kingsbury House DS0000000371.V377216.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 Kingsbury House DS0000000371.V377216.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for making sure that people’s needs are assessed before they are admitted into the home are satisfactory. This means that people can be confident that staff will know how to meet their needs following admission into Kingsbury House. EVIDENCE: The manager reported that people’s needs are assessed before a placement is offered at Kingsbury House. A sample of three people’s care records was looked at. All of the care records looked at contained a copy of the home’s preadmission assessment. Completion of this assessment helps the home to reach a decision as to whether a suitable placement can be offered. Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 10 The National Minimum Standards state that the home should obtain a summary of each person’s social services assessment before reaching a decision about whether to provide a place at the home. However, a copy of one person’s social services assessment was not available in their care records. The person concerned was admitted into the home before the current manager took up her post. Ms McNally immediately contacted the person’s care manager who forwarded the required information. Social services assessment information has been obtained for all admissions that have taken place since Ms McNally started working at the home. Kingsbury House DS0000000371.V377216.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for meeting people’s health and personal care needs are not fully satisfactory. This means that people using the service cannot be confident that their assessed needs will be well met. EVIDENCE: Following a requirement made in the last inspection report, improvements have been made to the quality of the home’s care plans. A range of care plans have been put in place for each person and cover a variety of areas such as mobility, nutrition and personal care. Care plans are generally reviewed monthly. People living at Kingsbury House, or their representatives, have signed the home’s care plans to confirm that they are satisfied with the content. Of the five staff that returned surveys, all said that they are given up Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 12 to date information about the needs of people they support. However, care plans covering people’s need for support with ‘end of life’ care and the management of their personal finances are not in place. Staff are clear about the action they need to take to make sure that people’s health care needs are met. People interviewed said that they felt confident that staff would be able to meet their health care needs. Of the eight people who returned surveys, all said that the home ‘always’ or ‘usually’ ensures that they get the medical care they need. People’s records show that arrangements are made for them to receive regular dental, chiropody and optical healthcare. Healthcare records show that GP intervention is usually arranged when necessary. However, one service user’s relative expressed concern at having to ask the home to request a GP visit following an accidental injury. Preventative health care risk assessments have been completed and are generally reviewed on a regular basis. For example, in the three sets of care records checked, nutritional, skin care and falls prevention risk assessments have been carried out for each person. However, the provider confirmed that people moving into the home do not routinely receive nutritional screening at the point of admission. It was also confirmed that staff have not received training in the management of malnutrition and providing assistance with eating. Also, inconsistent record keeping made it difficult to confirm that people’s weight is checked every month. Following requirements made in the last inspection report, a CQC pharmacist visited the home to check compliance. The pharmacist was satisfied that the provider and manager has taken appropriate action to comply with the requirements and recommendations set. For example, a controlled drugs cupboard has been installed. Medicines requiring cold storage are also kept secure. A pre-dispensed monitored dosage system is now in use helping to reduce the possibility of mistakes. A sample of medication records was checked. This showed that medication records are generally well maintained. The medication trolley is kept in a clean and hygienic condition. Two incidents involving the mis-administration of medication have occurred since the last inspection. The provider took appropriate action to safeguard the people in their care and systems have been put in place to prevent further reoccurrences. Observations of staff providing care showed that efforts are made to involve people in day-to-day decision making. For example, staff consult people about their meal choices on a daily basis. People said that staff always ask them about what time they want to go to bed. People’s care records contain information about their personal preferences regarding how they want to be cared for. However, people’s capacity to make decisions has not been assessed using the guidance provided by the Mental Capacity Act. Carrying out these Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 13 assessments will help staff to be clear about the decisions that each person can make and in what areas they might need help and support. The manager confirmed that the majority of staff have not completed Mental Capacity Act or Deprivation of Liberty training. Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for providing service users with a lifestyle that satisfies their social and recreational interests and needs, and nutritional requirements, are not fully satisfactory. This means that people are able to benefit fully from living in a home where the staff know how to meet their social care needs. EVIDENCE: The home obtains information about people’s social interests and hobbies before, and after, their admission into Kingsbury House. People’s care records contain a social history which helps staff to understand people’s life experiences before they moved into the home. A social needs care plan has been devised for each person and these are reviewed each month. This helps staff to be clear about how people’s social Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 15 needs are to be met. However, person centred activity plans have not been devised for people with dementia care needs. Kingsbury House employs an activities co-ordinator whose role it is to provide activities within and outside of the home. The manager reported that staff experience difficulties motivating service users to take part in planned activities. Although people’s care records show that social activities are provided, a formal activity programme is not in place. The activities coordinator provides a variety of social activities ranging from gentle exercise sessions to musical bingo and nail painting. Opportunities to participate in outside walks are also offered. A member of the catering staff provides flower arranging sessions which have proved popular. During the inspection, the activities co-ordinator was observed encouraging people to engage in social conversation and participate in walks along the sea front. Arrangements have been made for a local minister to give Holy Communion each month and a hairdresser visits weekly. Care plans setting out how staff should meet people’s religious and spiritual needs have been devised. Staff reported that more work could be done to provide people with access to in-house activities and trips out. One carer said that staff have very little time to deliver a programme of social activities in addition to their caring responsibilities. Visitors are made welcome and there are no restrictions on visiting times. People are able to meet with their visitors either in the home’s communal areas or in the privacy of their own bedrooms. The home has a rotating four-week menu that provides details of the food to be served at each mealtime. Breakfast is served from 8am onwards and tea from 4pm. Hot and cold food choices are available at all main meal times. Alternatives are always available and people can change their minds if they wish. People confirmed that they are consulted about meal choices on a daily basis. The inspector joined people for their lunchtime meal. There was a friendly and unhurried atmosphere in the dining area. The meal served was tasty and nutritious. It was nicely presented with good portion sizes. Of the eight service users who returned surveys, all said that they ‘always’ or ‘usually’ enjoyed the food served at the home. Kingsbury House DS0000000371.V377216.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for managing complaints and protecting the welfare of service users are not fully satisfactory. This means that people cannot be confident that they are being cared for by staff who will take appropriate action to keep them safe. EVIDENCE: The provider’s complaints procedure is displayed in each bedroom so that people using the service, and their families, know who to complain to and how to make a complaint. The procedure is included in the home’s service user guide. The manager was unable to produce a copy of the home’s complaints record. This failure was identified as a concern at the last inspection of the service. Of the five staff that returned surveys all said that they would know what to do if someone raised a concern. Of the eight surveys returned by people using the service, the majority said that they had been told how to make a complaint. The provider said that the home has received one complaint since the last inspection. This matter has been satisfactorily resolved. The CQC has also been Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 17 notified of one complaint which focused on issues to do with the home’s registration, the manner in which an allegation of theft by a person living at the home was handled, and issues around the timing of the administration of this person’s medication. These matters have recently been referred to the local authority’s safeguarding team. The CQC is concerned that the manager failed to notify the local safeguarding team and social services about the alleged theft that took place within the home. A Regulation 37 notification was not made to the CQC as required by the Care Homes Regulations. It was also established that the police were not informed about this matter. Ms McNally has since made the required notifications to the relevant organisations. Mrs McNally had not kept a written record of the allegation and the actions taken. A record of the incident had not been made. Failure to handle safeguarding concerns in an appropriate manner has the potential to place people using the service at risk. Although the home has a safeguarding policy, it has not been updated to take account of the provider’s responsibilities and duties under the Mental Capacity Act 2005 and the Deprivation of Liberty Regulations. Senior staff and carers are clear about the actions they would take to keep people. Staff said that they have read both the home’s Whistle-Blowing and Safeguarding policies and procedures. Kingsbury House DS0000000371.V377216.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of accommodation is not fully satisfactory. This means that people are not able to benefit from living in a home which is well-maintained. EVIDENCE: The home provides a physical environment that generally meets the needs of the people who live there. The home is comfortable, warm, well lit and clean. However, the decoration in some areas of the home is in a poor state. Arrangements are being made to redecorate all the bedrooms and communal areas over the next six months. Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 19 The home provides care for 10 people with dementia. However, the environment is not ‘dementia friendly.’ For example, ‘Way-Finding’ signs are not provided. The current decoration and paintwork scheme does not help people to make sense of the building and where everything is situated. Each person has access to their own bedroom but only some have private ensuite facilities. People can personalise their bedrooms if they wish. Toilets are appropriately located within the home, they are easily accessible and available in sufficient numbers. People have access to a range of aids and adaptations such as hoisting equipment and a ‘Stand-Aid’. Ms McNally said that appropriate aids and adaptations have been provided in all toilets. Following a check of the premises, a number of concerns were identified: • • • • • • A lockable facility was not available in one of the bedrooms visited. This means that the occupant is unable to secure their money and valuables within their room; The wardrobe in bedroom 3 does not have a door knob; The washbasin vanity units and general decoration in some bedrooms are in a poor condition; The flooring in the en-suite toilet in bedroom 6 is very stained; The carpets in some bedrooms are in a poor condition; The temperature of hot water supplied to one of the bathrooms measured 50c. This is in excess of the 43c recommended by the Health and Safety Executive. The manager took immediate action to resolve this matter on the day of the inspection. The faulty valve had only recently been serviced; The handles on the chest of drawers in bedroom 11 are missing; The adapted shower room on the second floor is out of order. A replacement part has been ordered; There is an unpleasant odour in some bedrooms; The light switch electrical covering was hanging down in one of the bathrooms. The socket was live and presented an immediate danger. The manager took immediate action to resolve the problem. It is of concern that this matter had not been identified earlier and made safe. • • • • Kingsbury House DS0000000371.V377216.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for ensuring that people using the service are in safe hands at all times are not fully satisfactory. This means that people cannot be confident that they will be cared for by staff who are suitable to work at the home and who are competent to do their jobs. EVIDENCE: There is a rota that shows, which staff are on duty and at what times. The rotas show that there are always a minimum of three staff on duty between 8am and 10pm for up to 30 people. Two staff cover the night-time period. Domestic and catering staffing levels are satisfactory. No concerns about the appropriateness of staffing levels were identified during the inspection. Of the seven staff that returned surveys, the majority said that there are sufficient staff on duty to meet people’s needs. A range of pre-employment checks is carried out before staff can start working at the home. For example, personnel files contain confirmation that staff’s identities have been checked. Criminal Records Bureau (CRB) disclosure checks Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 21 have been carried out and staff have been asked to supply a statement confirming whether they have any convictions or cautions. Following a recommendation in the last inspection report, a single application form is now in use. However, some staff have not provided a full employment history. Also, there is no documentary evidence in one staff member’s file that a matter of concern identified on their CRB disclosure certificate had been followed up by the manager. This could result in service users being cared for by staff who may not be suitable to work with vulnerable adults. Also, staff files do not contain an identification photograph or an up to date contract of employment. Testimonials have been accepted for some staff instead of written references. Failing to carry out all of the required pre-employment checks could result in unsuitable staff working at the home. Staff are provided with in-house induction training. This helps to familiarise new staff with the home’s environment and safety precautions. However, there is no documentary evidence that some staff appointed within the last 18 months have completed an induction covering the Common Induction Standards. All staff have obtained a recognised qualification in care. Staff are provided with opportunities to complete statutory training. A sample of three staff records was looked at. This showed that all staff have completed training in first aid, health and safety and fire prevention. Arrangements have been made for a newly appointed member of staff to complete training in moving and handling, food hygiene and infection control. Staff also receive extra training to help them meet the needs of people living at the home such as dementia awareness training. This helps staff to understand how people are affected by dementia and how they can provide person centred care. However, some staff have not completed Mental Capacity Act or Deprivation of Liberty training. Of the seven staff that returned surveys, all said that: their employer had carried out pre-employment checks before they started work at the home; their induction had covered what they needed to know to do the job; the training they are given is relevant to their role, helps them to understand the needs of the people they care for and keeps them up to date with new ways of working. The majority of staff said that they have the right support, experience and knowledge to meet the different needs of people using the service. Kingsbury House DS0000000371.V377216.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for ensuring that the home is properly managed and administered are not fully satisfactory. This means that people are not able to benefit from living in a home that is being run in their best interests. EVIDENCE: The manager holds the Registered Manager’s Award and has substantial experience of meeting the needs of older people within a residential setting. Mrs McNally regularly updates her mandatory training to ensure that her Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 23 practice is up to date. Although the home does not presently have a registered manager, Mrs McNally has recently submitted an application to register with the CQC. Mrs McNally said that she feels well supported by the provider who visits the home on a regular basis. Following a requirement made after the last inspection, the manager confirmed that arrangements are now in place to ensure that staff receive regular supervision. All staff have received at least two work based practice supervision sessions since the last inspection. Written records are being kept. A sample of the financial records kept on behalf of people was checked and found to be satisfactory. However, during a recent visit carried out by staff from the North Tyneside Contracts Unit, a range of concerns were identified. For example: the balance of money held on behalf of people had been checked and signed as correct when this was not the case; there wa evidence of poor record keeping, including the failure to ensure that the correct receipt is matched to the relevant entry on the financial record. The building is generally maintained in a safe condition. However, there were some exceptions to this and these have been dealt with earlier in this report. A selection of health and safety records was checked. These showed that the home has: • • • • An up to date fire risk assessment. Issues referred to in the assessment have been followed up with the home’s fire protection officer; Current gas and electrical safety certificates; Fire prevention safety checks are carried out on a regular basis; Carried out a range of workplace risk assessments. These assessments were up to date. However, the following concerns were also identified: • • • • Personal emergency evacuation plans have not been devised for each person; Some staff have not received fire instruction at the recommended frequency; The home’s hoisting equipment only received one service during the last 12 months instead of the usual two service visits; The six monthly service visit for the home’s lift was overdue at the time of the inspection. Kingsbury House DS0000000371.V377216.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 2 3 X 2 Kingsbury House DS0000000371.V377216.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 OP18 Regulation 13(6) Timescale for action Ensure that all safeguarding 01/09/09 concerns are reported to the Commission within 24 hours and social services are notified immediately. This will help to ensure that people using the service are properly protected. 2. OP19 23(2) Ensure that: • • The wardrobe in bedroom 3 is provided with a knob; The temperature of hot water supplied to service users’ bedrooms does not exceed 45c; The handles on the chest of drawers in bedroom 11 are replaced; The shower in the adapted bathing facility is repaired. 01/12/09 Requirement • • This will help to ensure that people are able to benefit from living in a well maintained home that meets their needs. 3. OP19 23(2) Ensure that: DS0000000371.V377216.R01.S.doc 01/03/10 Version 5.2 Page 26 Kingsbury House • • • Lockable facilities are provided in all bedrooms; Vanity units identified as being in a poor condition are replaced; The flooring in the ensuite facility in bedroom 6 is repaired. This will help to ensure that people are able to benefit from living in a well maintained home that meets their needs. 4. OP19 16(2) Take action to eliminate unpleasant odours that present in some bedrooms. the 01/10/09 are This will help people to benefit from living in a home which is odour free. 5. OP19 23(2) Ensure that: • • The decoration in all bedrooms is of a good standard; The carpets identified as being in a poor condition are replaced. 01/03/10 This will help to ensure that people are able to benefit from living in a well maintained home that meets their needs. 6. OP19 23(2) Ensure that all staff are aware of 01/09/09 the need to immediately report all health and safety concerns. This will help people to benefit from living in a home that promotes and protects their health and well-being. 7. OP29 Schedule 2 Ensure that: DS0000000371.V377216.R01.S.doc 01/10/09 Version 5.2 Page 27 Kingsbury House • • Staff provide a full employment history; Staff files contain a recent identity photograph. This will help to ensure that staff are suitable to work with vulnerable adults. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Ensure that care plans setting out how the home will help people to manage their personal finances are put in place. Care plans should address the good practice recommendations issued by the CQC. Ensure: • • • 3. OP10 That people receive nutritional screening during the first two weeks following their admission into the home; Staff receive training in managing malnutrition and providing assistance with eating; People’s weight is checked each month and a written record kept. 2. OP8 Ensure that: • • All staff complete Mental Capacity Act and Deprivation of Liberty training; An assessment of each person’s capacity to make decisions is carried out using the guidance provided by the Mental Capacity Act. A written record of the outcome should be placed in people’s care records. Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 28 4. OP11 Ensure that: • • Each person has an ‘end of life’ care plan that has been agreed with their family, GP and any other relevant healthcare professional; ‘End of Life’ care plans are subject to review by the multidisciplinary team, the service user and their carers/family, as and when people’s condition, or wishes, change; Where a person wishes to make an Advanced Decision about their ‘end of life’ wishes and preferences, the home seeks advice from the person’s care manager, GP and family; ‘End of life’ care plans are available to all people who have a legitimate reason to access it; All staff receive training in ‘end of life’ care; The provider’s ‘end of life’ policy covers Advance Decision-making. • • • • 5. OP12 Ensure that: • • • A person centred activity plan is devised for each individual with dementia care needs; Staff receive training in how to provide specialist activity sessions for people with dementia; Staff have access to specialist activity materials and equipment that will help them to deliver suitable activities for people with dementia. 6. OP12 Provide a programme of in-house and external social activities and events. Publicise this information to people using the service and their families to ensure that they are aware of what is going on within the home. Ensure that the home’s complaint record is available for inspection purposes at all times. Update the home’s safeguarding policy to ensure that it fits with the Mental Capacity Act and the latest developments within the field of adult safeguarding, including the Deprivation of Liberty Regulations. Ensure that: • • People are offered the opportunity to involve the police where their belongings or money have been stolen; A written record is kept of any incident affecting DS0000000371.V377216.R01.S.doc Version 5.2 Page 29 7. 8. OP18 OP18 9. OP18 Kingsbury House service users’ well-being. 10. OP19 Ensure that the building and its decoration are ‘DementiaFriendly.’ Seek advice from Experts in providing person centred dementia care facilities. Ensure that: • Documentary evidence is available to confirm that matters of concern disclosed on staff CRB disclosure certificates have been followed up and discussed with the person concerned. The manager should also ensure that the guidance issued by the Care Quality Commission about how to handle CRBs where convictions have been disclosed is followed; The home’s employment policies and procedures comply with the guidance issued by the Care Quality Commission about how to handle CRBs; Staff files contain an employment contract; Testimonials are not accepted in lieu of written references. 11. OP29 • • • 12. OP30 Ensure that newly employed staff complete an induction covering the Common Induction Standards. A certificate of completion verified by the manager, or other relevant body, should be available within the home. Ensure that all staff complete training in the Mental Capacity Act and the Deprivation of Liberty Regulations. Submit an application to register a manager for the home. Ensure that the financial record keeping concerns identified by staff from the North Tyneside Contracts Unit are addressed. Ensure that: • • • Each person has a Personal Emergency Evacuation Plan; Day staff receive at least two fire instruction training sessions per year. Night staff should receive at least four sessions; The home’s hoisting equipment and lift receive a minimum of two maintenance service visits per year. 13. 14. 15. OP30 OP31 OP37 16. OP38 Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 30 Kingsbury House DS0000000371.V377216.R01.S.doc Version 5.2 Page 31 Care Quality Commission Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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