Inspection on 06/06/05 for Kingsbury House Care Home

This inspection was carried out on 6th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kingsbury House Care Home 17/10/07

Kingsbury House Care Home 07/08/06

Kingsbury House Care Home 07/11/05

Kingsbury House Care Home 16/02/05

Kingsbury House Care Home 19/10/04

Kingsbury House Care Home 17/03/04

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

CARE HOME ADULTS 18-65 Kingsbury House Care Home Address 1 103 Mansfield Street Sherwood Nottinghamshire NG5 4BH Lead Inspector Jayne Hilton Unannounced 6 June 2005 @ 10:00 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kingsbury House Care Home Address 103 Mansfield Street, Sherwood, Nottinghamshire, NG5 4BH 0115 955 2917 0115 955 2919 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Andrew Richard Schofield Ann Schofield CRH 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (MD) of places Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16/2/05 Brief Description of the Service: Kingsbury House care home is registered to accommodate up to 11 people who have experienced mental health problems.The home comprises of two separate semi-detached properties. 105 Mansfield Street can accommodate up to three people. It has bedrooms to the ground and first floor, a shared lounge and dining kitchen. One staff member lives in at the property.103 Mansfield Street provides an additional 8 bed spaces. Accommodation is arranged on two floors. There is a non-smoking dining room and a lounge where smoking is permitted. Currently one staff member lives in at the property. Sleep in accomodation is also provided for staff. None of the rooms have en-suite facilities.The home is situated in a residential area of the city within easy walking distance of a range of shops and public amenities. Off street car parking is available.The homes were previously registered separately however the Commission has granted an application to vary this by combining the registrations as one.The proprietor is Mr A Schofield and the Registered Manager is Mrs Schofield. Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection, which was carried out by, two inspectors, Jayne Hilton and Elaine Cray was of a duration, of four and a half hours. The methodology used included, assessing the requirements set at the previous inspection, speaking with four service users in detail and others throughout the course of the inspection, two staff, the registered manager and the registered provider. A sample of records was examined and a tour of the environment was undertaken. Three care plans were also examined. What the service does well: What has improved since the last inspection? Training has been provided for staff in mental health awareness and Dementia. A booking has been made for staff to attend training in adult protection. A business and financial plan has been produced and there have been some improvements to the care plans particularly in identifying any restrictions imposed on freedom and choice on individuals. Some decorating and provision of two new chairs has taken place. Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 6 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. Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3,4,5 Service users are happy that their needs are met, have a detailed assessment of their needs undertaken and are provided with a contract statement. Prospective service users can visit the home prior to admission. EVIDENCE: Four service users were spoken with and all said they felt well cared for and listened to. All had seen or knew of their care plans. Three care plans were examined all had terms and conditions/contracts which had been signed by the service user. The assessment document was detailed and contained all aspects as required in standard 2.3 and contained a record of social worker reviews. A social worker was visiting the home on the day of the inspection. A copy of the Care Programme Approach care plan was in place where applicable. Any restrictions imposed were documented and signed for by, the individual, the requirement set, at the last inspection, regarding this is therefore met. [see also standard 9] There was evidence on a newly admitted service users file that he had been for trial visits and the observations made at the visits were kept on the service users file. Service users discussed visiting the home before moving in, with the inspector. Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9,10 Service users are aware of their care plans, which contain information about their individual needs and wishes, however the plans do not show evidence of how the needs have been met, or demonstrate a process of evaluation and monitoring. Service users are encouraged to make decisions about their lives and are supported where necessary to make decisions and take responsible risks. Service users are aware of information stored about them and the confidentiality policy is practiced within the home. EVIDENCE: Three care plans were examined and found to contain information of what is required to meet the individual needs of service users, their likes, dislikes and requests/aspirations. Service users were clearly involved within the compilation of these and had signed and agreed them. Those service users who needed assistant confirmed that staff had read their plan of care for them. Care plans were reviewed but the process of evaluation and monitoring was not apparent. Daily notes are taken by the staff which could be summarised monthly or three monthly, covering the holistic needs and daily lifestyles of service users, for example, where a service user has stated that he/she would like to attend a religious service or visit a priest, then there must be some evidence of how the Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 10 home has endeavoured to assist the service user to meet those needs. There was evidence that service users were involved in decision making in the home, however the facility of resident meetings had been discontinued for various reasons. Service users expressed to the inspector that they would like meetings to be revised and arranged so that service users can opt out of attending should they wish. Staff demonstrated a good knowledge of the service users. Four service users confirmed they were involved in the day to day running of the home such as helping to prepare meals, cleaning up, decorating, tidying rooms and deciding what goes on the menus. A service user was observed helping with washing the dishes after lunch [service users should be reminded to wear an apron for these tasks] Any restrictions imposed are documented on the individuals care plan with the service users signature. [ A requirement set at the last inspection was assessed as met] Risk assessments were noted in the three plans examined. Service users felt that they could trust staff and that it was good to be open and honest and try to sort things out. Service users confirmed that they could see any information written down about them at any time. Policies were examined regarding confidentiality and staff had signed a confidentiality statement within their employment folders. Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13,14, 15,17 On the whole service users have opportunity to engage in leisure activities and belong to various community groups. They have opportunities for personal development and their rights are respected. Service users maintain family contact and relationships where appropriate, Service users do enjoy their meals and mealtimes but further work is required to ensure that service users have a healthy and nutritional intake of balanced food items. EVIDENCE: The four service users spoken with were observed to have a positive and interactive relationship with each other. Service users confirmed that their relatives visited the home and that they visit their family and friends in the community. One service user went to meet his father during the inspection. Service users confirmed that they get up at different times and go out as they please. A member of staff reported that the three service users who live at 105 go to bed early, the manager confirmed this was their choice and that staff would stay up on the occasions a service user wished to stay up later. Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 12 Service users were observed getting up at various times throughout the day of the inspection. They explained to the inspector their differing interests and community involvement, which include, a community art group, Open door group, run for people with mental health difficulties and Brook St group meetings and chat in at Sherwood Community Centre. One service user enjoys car boot sales, walking in the park, card games and visiting the pub for a meal. It was recognised from the inspection that more innovative use of activities could be beneficial to reducing anxiety and boredom for service users. There was no budgeted funds for holiday provision in the financial plan examined, however a service user commented that she was planning a trip to Skegness with two other service users. Several other trips out were noted to be planned, and were posted on the notice board in the dining room, these included a boat trip, and Christmas meal\out. The manager had prepared a new four- week cycle of menus, which was on display and offered a choice of two options, however this had not been implemented. The manager reported that service users may not want either item and enquired if other options could be made available depending on what was in stock. The Inspectors advised that more choice options the better. The menu offered should however be the basis for a nutritious and varied diet, which is important and although service users are encouraged to make their choice, the staff should provide guidance to service users to encourage healthy eating options. All service users spoken with during the inspection did not know what they were having for lunch or tea and the menus were not displayed in 105 at all. Some service users were noted to buy their own food snacks and items, which, is perhaps indicative that there was a lack of availability of these items in the home. That said service users reported that the food was good. One service user stated his favourite food was pork chops, however there was no record in his book of this preference. There was evidence of a lack of food stocks in 105. Meals were, reported to be, cooked at 103 and transported across to 105. The manager stated this only happened on odd occasions. It was reported that food is delivered on Wednesdays or Thursdays. The cupboards in 103 were relatively well stocked but tended to be tinned, supermarket own brand items and frozen high fat content produce such as beef burgers, sausage and meat pies. The staff and manager confirmed fresh fruit and vegetables are purchased daily and that service users shop for these items. There was a fruit bowl in 103 with two apples and a bag of potatoes in the kitchen. Frozen peas were the only source of other vegetables seen in the home. On examination of the individual food records kept for each person there was lack of evidence of intake of fruit and vegetables. There is still much scope to improve the nutritional intake of service users. One service user reported that she has a food hygiene certificate and the manager reported that she is looking into staff undertaking training in food values and nutrition. The kitchen in 103 is currently under-used and would be an ideal area for home cooking classes and for group work on education work around nutrition Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 13 and healthy living and particularly as a service user has requested more opportunities for improving catering skills. Service users did express a satisfaction with the food provided. The inspector advised that more evidence will be required at the next inspection in the assessment of whether the requirements from the last inspection have been fully met. It has been acknowledged that there has been some effort made, regarding the preparation of the new menu, however food receipts will need to be examined in relation to the menus and documentation of food intake at the next inspection. With innovation this standard could be more than met and possibly exceeded. Several recommendations have been set alongside the requirements that are outstanding. During the inspection service user asked the member of staff what was for lunch. Service users were offered, egg on toast, egg sandwich, scrambled egg, sardines on toast or cheese on toast. All four service users, made a different choice which was respected. Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20, 21 Service users personal and healthcare needs are generally met, however the documentation of healthcare checks needs to be improved. The systems for managing medicines in the home is overall satisfactory, however there are some aspects that need to be improved. Service users have expressed their wishes for the end of life and this is well documented. EVIDENCE: The service users confirmed that they receive support when needed. Evidence was seen of the involvement of a wide range of healthcare professionals that enables prompt referral to other appropriate services, for example, the Dual Diagnosis team. The manager reported that service users access local General Practitioner (GP) services and other resources such as dentists etc and that appointments are recorded in the diary or in daily logs The details of these should be included in the care plans including ensuring/encouraging an annual well person check for each individual. Some people have regular visits from healthcare professionals such as Community Psychiatric Nurses and Occupational Therapists. This involvement from a wide range of healthcare professionals enables prompt referral to other appropriate services, for example, the Dual Diagnosis team, Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 15 where necessary. The manager reported that one service user has avoided appointments on occasions. The inspectors advises that due to the needs of service users staff need to approach the GP to facilitate home visits where needed under certain circumstances. Healthcare records should also be kept within the individual plan of care. Plans for managing individuals behaviour should also be evaluated and monitored this way. Medication profiles should also be included in the care plan and include details of medication reviews. The storage facilities of medication and relative procedures were examined. The home has a British National Formulary dated 2000. Although these are published every six months it is recommended that a new one be acquired at least annually. Records of the temperature medication is stored were examined, these were not taken regularly and should be taken weekly as routine. Insulin was stored in a locked box in the kitchen fridge, which is not, appropriate in relation to, the assessed needs of service users who live in the home. It is recommended that a small fridge be provided in the medication room for this purpose. Staff have undertaken medicine management training, competency assessments should also be carried out at intervals and as part of staff supervision. Additional training is provided by, the dispensing pharmacist. The wishes of service users for the end of their life were documented in care plans and service users and the manager talked about a service user who had died in hospital in the last year. As some service users are now nearing the age of sixty years the policy for increasing frailty and care plans addressing ageing should be reviewed. Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 Service users are aware of how to make a complaint and are confident that this would be dealt with appropriately. Service users are protected by systems to prevent abuse. EVIDENCE: There was a complaint procedure in place, which meets the standard set. Service users reported that they can talk to staff and they will sort it any problems. Service users were aware of the procedure displayed in the hallway. There were no complaints recorded in the complaints folder and service users spoken with confirmed they had not made any complaints themselves but were aware that staff may not always be able to sort some issues out, for example when some service users are rude or bossy. There is a policy for dealing with harassment and bullying, however it was felt by the inspectors that improved documentation of concerns and conflict issues would demonstrate how staff dealt with these issues and resolved conflicts within the resident group. The registered manager has the procedures relating to the Protection of Vulnerable Adults (POVA). There is a Whistle Blowing policy displayed and staff have signed that they have been issued with a personal copy. Training in adult protection has been booked, however there is a waiting list due to demand. Staff have been given opportunity to watch a training video an protection of vulnerable abuse. Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28, 30 Service users live in a homely environment and have bedrooms to suit the needs, lifestyles and which promote independence however, staff support is needed to assist service users to maintain cleanliness of their rooms and bed linen. Service users communal space is somewhat compromised by lack of facilities for meetings, which should be addressed. Service users contribute to keeping the home clean and hygienic practices were promoted in general. All water outlets are not regulated to safe temperatures and service users are being placed at risk of scalding. The surface temperatures of radiators must be risk assessed and appropriate action taken to minimise risk where identified. EVIDENCE: The registered manager has acknowledged that the home is in need of some redecoration and refurbishment. Some areas have been completed since being identified at the last inspection. It was also identified that more lounge chairs Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 18 are required. Two chairs have been added to the lounge area. The registered manager has devised written plan for the redecoration and refurbishment of the home. It states that a new suite would be provided in 105 by May 2005, this has not been achieved to date. Two of the three service users asked, gave consent for the inspector to examine their bedrooms, both rooms were well personalised. One service users bed linen was in need of changing, and had clearly not been changed for a while. Staff should assist service users to maintain cleanliness where this is assessed as needed. Bedroom sizes meet with the national minimum standards as an existing establishment prior to The Care Standards Act 2000. The number of toilets and bathrooms appeared adequate and were clean. There is a bolt on the bathroom door in 105, which, should be changed for a thumb turn lock which staff can over - ride in an emergency. An incident occurred during the inspection, which, highlighted that the water was extremely hot. A repair was carried out by, the provider to fix a broken tap. The manager had undertaken temperature tests for the prevention of legionella, however there were no records of water outlet temperatures being taken. It also came to light that there were no regulating valves in number 105. Despite the provider reporting that 103 did have regulating valves the temperatures taken were on average 57 degrees. As there is a risk of scalding an immediate requirement was set for the situation to be remedied within 28 days. Some radiators were of the low surface type and others were reported, to be regulated, risk assessments should be carried out for these. The situation regarding one service user who does not use the lounge at number 103 Mansfield Street because it is a smoking area has not been resolved, however the manager pointed out that the facilities were explained to the service user on admission. The dining room is the no-smoking area in the home and is also used for private meetings. This is problematic as it is the only communal space that the non-smoking service user feels comfortable using. It is clearly unfair that he is excluded from the dining when private meetings take place. The registered manager must discuss this with the service user in question and if necessary consider alterative arrangements for meetings. The issue was again discussed at this meeting and there is clearly a lack of space for administration and meetings. Care plans are currently being stored in the staff toilet area in a lockable filing cabinet but this is not ideal. The filing cabinet had previously been sited in the dining room. There are some garages in the grounds and the manager reported that it has been discussed that there is a possibility for conversion into office space and meeting room facilities. This idea would be supported by, the inspectors and manager who Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 19 had paperwork everywhere. The other possibility would be for a summer house conversion. The communal areas are kept clean overall. Policies are in place for the control of infection. The laundry in 103 is sited so that articles are not carried through areas where food is stored or prepared. In 105 access to the laundry is through the kitchen. The manager explained that sealed bags are used for transportation of linen. Hand washing facilities are prominently sited in areas where infected material could be handled and soap dispensers are available. The kitchen was noted to be clean. Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 33, 34, 35 Service users benefit from being supported by, an effective, competent and committed staff team. Service users are protected by safe recruitment practices, however there are records missing from staff files. EVIDENCE: Two staff, were interviewed and confirmed induction and shadowing had been undertaken when newly employed. Staff were not sure whether they had supervision, however there was evidence that this had been undertaken within staff personal files. The staff members interviewed, were confident about their roles and responsibilities. Staff confirmed that they had seen care plans and discussed their understanding of service users needs with the inspector. Staff also discussed their involvement in activities with service users. Observations of interactions with service users demonstrated a consultative approach, with a warm rapport with service users. Two staff presently live - in on site and the rota demonstrated two staff on each shift in 103 and one in 105. The manager works in addition mostly but does cover some shifts. 1 member of staff sleeps in each property. The requirement set for Standard 29 at the last inspection no longer applies as the staff member has since resigned, however on examination of the staff files Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 21 they were not complete as specified in Schedule 2 requirements, these must contain a photograph and proof of identification such as a birth certificate or driving licence. POVA first checks and Criminal records bureau checks were in place. A medical questionnaire is also in place, it is recommended that this contains a clear signed statement of the member of staff that they are physically and mentally fit to carry out the tasks in their job description. Staff confirmed that they have been issued with a copy of the GSCCC [General Social Care Council’s Code Of Conduct] booklet. Training records examined, identified a god level of training provision which included Health and Safety, Manual Handling, First aid, Dementia Care, Mental Health Awareness, Fire Safety, Infection Control and Food Hygiene. The inspector advised the manager to expand on the medical questionnaire statement to ensure that staff were signing a declaration that they were physically and mentally fit to undertake the duties of the job description and to give permission to contact their GP if necessary. Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39, 40, 41, 42, 43 The management of the home is generally good, however the quality monitoring systems are not sufficient and need to be further developed. The record keeping is generally satisfactory, however there are some aspects to address to improve this. A wide range of policies and procedures are in place, but these need to be reviewed at least annually to ensure service users rights and interests continue to be protected. The health and safety and welfare of service users is generally met but is compromised by the hot water system issue raised. EVIDENCE: The registered manager is currently working to achieve the NVQ 4 Registered Managers award. All other staff, have achieved NVQ2 OR 3 or are waiting to enrol on training. Quality assurance systems have been implemented in the form of a service user questionnaire, however the recommendation made at the last inspection is only partly met, A survey was carried out last in Feb 05 and is dated, Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 23 however the use of independent parties has not yet been utilised. The provider, although not required legally to, as the providers are in day to day control of the home, should carry out regulation 26 type audits and integrate this with the development and financial plans of the home. There is a policy manual, which was examined by the inspector, and identified that, the last review date of these was 2003. A sample of records were examined, including fire records, accident records, training records, staff personal files, care plans, water temperature outlets, complaints and staff rotas, all apart from those discussed within the context of the report were satisfactory. Some health and safety aspects were inspected. The Environmental Health Inspector had made two visits and made recommendations regarding the prevention of legionella checks and regarding storage and defrosting of meats in the refrigerator. He also required that eggs must be stored in the fridge and that a foot operated bin be purchased. The inspection was in March 2005, a pedal bin has not yet been purchased, the inspector made suggestions as to where a suitable type could be purchased easily. The issue of unregulated hot water systems compromises the health and safety and welfare of service users. The business and financial plan was examined, this has to yet be ratified with the providers accountant/solicitor. The inspector pointed out that there was no provision made for holidays or activities and this needs amendment to rectify this. The insurance arrangements were examined and found to be satisfactory. Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 2 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 2 3 x 1 Standard No 31 32 33 34 35 36 Score 2 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kingsbury House Care Home Score 3 2 2 3 Standard No 37 38 39 40 41 42 43 Score 3 x 2 2 2 1 2 C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA 7 Regulation 14, 15 Requirement Timescale for action 6/9/05 2. YA 17 3. YA 17 4. YA17 5. YA24 6. 7. YA34 YA42 Care plans must contain evidence of a process of evaluation and monitoring to demonstrate how the documented needs of service users are being addressed 12,1 3, A menu must be developed that 16, 17 reflects the service users personal choice and individual dietary needs. This is an outstanding requirement from the previous inspection. 12, 13, The registered manager must 16, 17 ensure that food stocks are available to provide the stated menu. This is an outstanding requirement from a previous inspection. 12, 13, 16 The quality and quantity of food stocks must provide a nutritious, varied and balanced diet. This is an outstanding requirement from a previous inspection. 23 Continue the programme of refurbishment as specified in the development and maintanence plan 7, 9,19 Ensure all staff files contain all documentation as specified in schedule 2 of the Regulations. 12, 13, Ensure water outlet C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc 6/9/05 6/9/05 6/9/05 6/9/05 6/9/05 Immediate Page 26 Kingsbury House Care Home Version 1.30 16, 23 8. YA42 16 temperatures are regulated to 43 degrees within 28 days Ensure the recommendations 6/9/05 made by the Environmental Health Officer are carried out 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. 3. 4. 5. Refer to Standard YA 7 YA14 YA14 YA17 YA19 Good Practice Recommendations Re-instate the resident meetings Provide funding for holidays for each srevice user The registered manager and staff should be innovative in providing activities for individuals to reduce anxiety and boredom. Use a page a day diary to record service users food intake and other kitchen records Ensure all service users have the opportunity to have an annual well person check[ routine smears and breast screening] and that this is documented in the individuals plan Be instrumental in supporting service users to remember to attend medical appointments and be instrumental in approaching medical personnel to be sensative to individual circumstancesl Include record sheets for attendance of healthcare checks within the care plan Include a medication profile for each individual in the care plan and update information regarding medication reviews and information on mediaction and their contraindications etc. A new British National Formulary (BNF) should be purchased annually. Carry out and document the medication storage temperatures weekly Provide a fridge in the medication storage room. Repair the broken handle on the medicine cupboard Competency assessments should be carried out periodically of staff dispensing medication. Improve documentation to address concerns expressed by service users and conflict issues of service users and how staff have dealt with the issues C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 27 6. YA19 7. 8. YA19 YA19 9. 10. 11. 12. 13. 14. YA20 YA20 YA20 YA20 YA 20 YA22 Kingsbury House Care Home 15. 16. 17. 18. 19. 20. 21. 22. 23. YA26 YA27 YA27 YA27 YA27 YA39 YA39 YA40 YA43 Assist and guide service users with room cleaning and promote regular changes of bedlinen. Provide a type of privacy lock in the bathroom that has an overide facility for staff to gain access in an emergency Ensure records are kept of water outlet temperatures and include any action taken to remedy any that record over 43 degrees and which incorporate a retest record Provide evidence that the surface temperatures of radiators have been risk assessed. Consider alternative arrangements for meetings and the possibility of the garage conversion or similar. Further develop the quality monitoring and auditing systems Use the regulation 26 format to undertake monitoring of action plans Review policies and procedures annually Ensure provision is made within the financial plan for activities and to fund an annual holiday for each service user Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 28 Commission for Social Care Inspection /Edegley House Riverside Business Parkl Tottle Road Nottingham NG2 1RT 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. Extracts may not be used or reproduced without the express permission of CSCI Kingsbury House Care Home C53 C03 S2301 Kingsvury House V231175 060605 Stage4.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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