Inspection on 07/08/06 for Kingsbury House Care Home

This inspection was carried out on 7th August 2006.

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 no outstanding requirements from the previous inspection report, but made 2 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 07/11/05

Kingsbury House Care Home 06/06/05

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 103 Mansfield Street Sherwood Nottinghamshire NG5 4BH Lead Inspector Jayne Hilton Key Unannounced Inspection 7th August 2006 02:30 Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 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 Kingsbury House Care Home DS0000002301.V306904.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 Adults 18-65. 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. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 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 kingsbury.carehomes@ntlworld.com 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) Mr Andrew Richard Schofield Ann Schofield Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 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. Access to the second floor is by staircase only, therefore the home would not be suitable for people with physical disabilities. There is a nonsmoking dining room and a lounge where smoking is permitted. Currently one staff member lives in at each of the properties. Sleep in accommodation 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. Details of the fees provided on 7th August 2006 by Mrs Schofield range between £282.99-£323.56. Service users are expected to fund extras for example, toiletries hairdressing, chiropody, newspapers etc. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection was carried out by, one inspector, on the afternoon of 7th August 2006 for a duration of four and a half hours. The inspector used a method of inspection called “case tracking”. This involved identifying individual residents who currently live at the home talking with them about their experiences, examining records and discussing care practices with staff and the manager. What the service does well: Service users reported being 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. Service users are aware of their care plans, which contain information about their individual needs and wishes and are reviewed, they are encouraged to make decisions about their lives and are supported where necessary to make decisions and take responsible risks. All service users spoken with were observed to have a positive and interactive relationship with each other and staff members present. Service users and staff confirmed that their friends and relatives visited the home and that they visit their family and friends in the community. Service users confirmed that they get up at different times and go out as they please. They explained to the inspector their differing interests and community involvement. 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 said they enjoy their meals and mealtimes and they can retain and administer their own medication. Service users also 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. Service users informed the inspector that they are aware of how to make a complaint and are confident that this would be dealt with appropriately. Service users live in a homely environment and mostly have bedrooms to suit their needs and lifestyles and which promote independence. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 6 Service users benefit from being supported by, an effective, competent and committed staff team and are protected by safe recruitment practices. Service users benefit from a well run home and are confident their views underpin all self monitoring review and development of the home. The health and safety and welfare of service users are promoted and protected. What has improved since the last inspection? What they could do better: The care plans do not always show evidence of how the needs of individuals have been met, or clearly demonstrate a process of evaluation and monitoring. Service users personal and healthcare needs are generally met, however the documentation of some healthcare checks and input needs to be improved. Risk assessments were not in place for a service user who self medicates. The Registered Provider must ensure that appropriate notifications are made to CSCI as required by regulation. A requirement is set in relation to this. Improved staff support is needed to assist service users to maintain cleanliness of their rooms and bed linen. Service users comfort may be compromised by a lack of table facilities. A requirement is set in relation to this. Improved practices in the prevention of mal odour are identified as needed. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 7 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 DS0000002301.V306904.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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: The home is registered as Care Home for People with Mental Health Difficulties. This Registration was transferred to The National Care Standards Commission [NCSC] in July 2002 and subsequently remains as such with CSCI [Commission For Social Care Inspection]. The Registration category includes exclusion in relation to People with Leaning Disabilities and for people with Dementia. Kingsbury House did have a resident with a learning disability at the time of transfer to NCSC and therefore continues to provide support for this person on an agreed basis. On the day of the inspection nine service users were in residence. One service user has recently moved from the home. Four service users were spoken with and all said they felt well cared for and listened to. Three care plans were examined all had terms and conditions/contracts which had been signed by the service user. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 10 The assessment document was detailed and contained all aspects as required by National Minimum Standards [Standard 2.3] and also contained a record of social worker reviews. Any restrictions imposed, were deemed to be in the best interests of service users safety were documented and signed for by the individual. Restrictions were in place for smoking in bedrooms, food preparation etc. There was evidence on service users files that they had been for trial visits and the observations made at the visits were kept on the service users file. The manager discussed trial visit arrangements proposed for a prospective new service user. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are aware of their care plans, which contain information about their individual needs and wishes and are reviewed. Service users are encouraged to make decisions about their lives and are supported where necessary to make decisions and take responsible risks. EVIDENCE: Three care plan files were examined and contained information of what is required by staff 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. Care plans were signed and dated as reviewed, however where needs were noted to have changed, this had not always been identified within the evaluation and monitoring process for example: One individuals care plans had not been fully updated with relevant information, in relation to current continence support and vulnerability in the community and the diet assessment needs sheet had not been updated, Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 12 neither had a care plan been devised for this particular identified need. Daily notes are taken by the staff, which covers the holistic needs and daily lifestyles of service users. There was some evidence from resident meeting notes, that service users were involved in decision making in the home, and resident meetings had been recommenced. Staff reported that service users were not always motivated to attend the meetings and that it was usually the same people who attended. 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. Any restrictions imposed are documented on the individuals care plan with the service users signature. Risk assessments were noted in the three plans examined apart from one risk assessment, which could not be located in relation to self -medication. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. EVIDENCE: All service users spoken with were observed to have a positive and interactive relationship with each other and staff members present. Service users and staff confirmed that their friends and relatives visited the home and that they visit their family and friends in the community. Advocacy services are involved in the home currently for one service user. Details were seen about this in the service users care plan and there is also evidence from a recent strategy meeting minutes. The Registered Provider reported that there are some difficulties currently between the Provider and the advocacy service which both are trying to resolve. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 14 Service users confirmed that they get up at different times and go out as they please. They explained to the inspector their differing interests and community involvement, which include, a community art group, ‘Open door’ which is a group, run for people with mental health difficulties and Brook St group meetings. Service users also said they attend ‘chat in’ at Sherwood Community Centre, go to car boot sales, walking in the park, play card games and enjoy visiting the pub for a meal. Staff and service users reported that they attended a bonfire party at the provider’s house which all enjoyed. Board games and cards are provided for in house activities. Staff members said that service users had taken holidays with families but there have been no planned or arranged holidays from Kingsbury House. Service users reported that staff, treat them respectfully, by knocking on their doors and waiting to be invited in and speak to them in a respectful manner. The staff and service users had prepared a cycle of menus, which was on display and offered a choice of two options apart from when there is a roast on offer. Service users and staff confirmed that other options from the cupboard could be taken if they did not wish to have what was on the menu. Service users confirmed that there is a free choice of breakfast options. The menu offered a nutritious and varied diet, which is important and although service users are encouraged to make their choice, the staff said they provide guidance to service users to encourage healthy eating options. Staff said they have undertaken training in food and nutrition, certificates for this training was seen. Overall there was evidence that the food provision has improved and service users spoken with confirmed that the food is good and that they enjoyed their meals. Stocks of food reflected the meal options on the menu. The staff confirmed fresh fruit and vegetables are purchased daily and that service users shop for these items. A good supply of fresh and frozen foods was seen in the home. One service user chooses to eat in his room, but there was no table other than a low small coffee table provided. The facilities therefore do not meet his needs. A suitable table must be provided. [See standard 26.] A jug of juice and beakers were supplied in the lounge for service users to access as needed. Service users confirmed they could make drinks as they wished and one service user had a kettle tipper aid to assist this. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users personal and healthcare needs are generally met, however the documentation of some healthcare checks and input needs to be improved. Service users can retain and administer their own medication. The systems for managing medicines in the home are satisfactory. Risk assessments however were not in place for a service user who self medicates. EVIDENCE: 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. The manager reported that service users access local General Practitioner (GP) services and other resources such as dentists etc. The inspector found that details of these are now included in the care plans including ensuring/encouraging an annual well person check for each individual where they wish to take up this offer. 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, where necessary. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 16 Plans for managing individuals behaviour were seen to be in place and arrangements were being looked at by the manager to ensure that staff have the appropriate training to meet the current service users needs. As already identified there were some identified needs of service users that should be more detailed in care plans, such as ongoing monitoring of continence issues, sexual health and dietary input. Medication profiles were noted to 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 an up to date British National Formulary. Evidence was seen of training certificates, that staff, have undertaken medicine management training. Additional training is provided by, the dispensing pharmacist. Policies and procedures were seen for the management of medicines, which appeared satisfactory. One resident self medicates, and has lockable facilities for this purpose. The manager stated that a risk assessment had been documented but this was missing from the resident’s records. The Manager agreed to undertake a new one and send a copy to the CSCI. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 22, 23, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are aware of how to make a complaint and are confident that this would be dealt with appropriately. Systems were not fully in place to protect service users from abuse, improved monitoring and training would ensure service users are fully protected. The Registered Provider must ensure that appropriate notifications are made to CSCI as required by regulation. EVIDENCE: There was a complaint procedure in place, which meets the National Minimum Standards. Service users reported that they can talk to staff and they will sort out any problems. Service users were aware of the procedure that was observed displayed in the hallway. There were no complaints recorded in the complaints folder in the home and service users spoken with confirmed they had not made any complaints themselves. There is a policy for dealing with harassment and bullying, there had been a recent complaint made to Social Services in relation to staff conduct at the home and which Social Services had investigated as the Lead Agency under Safeguarding Adults Protocols. The complaint was not substantiated, but an action plan had been devised by the Provider to improve practices in the home and to review policies for clearer guidance for staff. Staff spoken with reported that they had perhaps overstepped professional boundaries, by treating service users as friends and had accompanied service users on outings on their days Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 18 off. The manager and staff spoken with confirmed that action had been taken to ensure staff understood the professional boundaries of their post. A copy of the procedures relating to the Protection of Vulnerable Adults (POVA) is available at the home. 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, the inspector has seen a letter from the Adult Protection Unit conforming this. Staff confirmed they have been given opportunity to watch a training video on protection of vulnerable adults from abuse. From the examination of care plans it was noted that some incidents had not been recorded as an official incident and that CSCI had not been notified of these events. There was no record at CSCI office that the complaint reported above had been submitted to CSCI without delay, although the manager said she thought she had sent this. Copies were later received at CSCI. The registered person is therefore required to ensure that any event affecting the health or welfare of a resident is notified without delay to the commission. [See also Standard 41] A sample of service users personal finance records were examined and all appeared satisfactory. The records were audited and receipts in place as needed. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 19 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 the following standard(s): 24, 25,26, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a homely environment and mostly have bedrooms to suit the needs, lifestyles and which promote independence however, and improved staff support is needed to assist service users to maintain cleanliness of their rooms and bed linen. Service user’s comfort may be compromised by lack of table facilities. Service users live in a generally clean and hygienic environment but improved practices in the prevention of mal odour are identified as needed. EVIDENCE: The registered manager acknowledged at a previous inspection that the home was in need of some redecoration and refurbishment. Some areas have been completed since being identified at the last inspection. It was also identified at the previous inspections, that more lounge chairs were required. Two lounge chairs have been added to the main sitting room area and a new settee and lounge chair provided in the dining room. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 20 There was also identified, continence issues in two rooms that need to be addressed to maintain the dignity of service users. One room had mal- odour Staff should assist service users to maintain cleanliness where this is assessed as needed. As identified under Standard 17, one service user should have facilities provided to enable him to eat in comfort in his room. Evidence was seen that a system had been put in place to prevent legionella, but water outlet test records were not routinely taken. Some radiators were the ‘low surface temperature’ type and others said by the manager to be regulated. Risk assessments should be carried out to identify any potential risks to service users. This issue has been identified at a previous inspection but no risk assessments were provided for examination at this inspection. As there appeared to be some confusion about continued maintenance of legionella prevention, water outlet temperatures and radiator surface temperature risk assessments. The Registered Provider is advised to consult with the Environmental Health Officer about ensuring safe systems. Records and staff comments evidenced that staff have undertaken training in infection control and food hygiene. The communal areas are kept clean overall. Policies are in place for the control of infection. The practices followed within the home were examined and constitute good practice regarding the management of the control of infection. There were some issues identified in relation to cleanliness of some service users rooms. Staff said they do assist service users where necessary with their rooms but this clearly needs to be improved to ensure the home is kept clean and fresh smelling. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 21 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from being supported by, an effective, competent and committed staff team. Service users are protected by safe recruitment practices. EVIDENCE: Two staff were interviewed and confirmed induction and shadowing had been undertaken when newly employed, records were examined also. Staff confirmed they had supervision and appraisals and 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. 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 to the rota mostly but does cover some shifts as needed. 1 member of staff sleeps in each property. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 22 Four staff files were examined in relation to recruitment and all contained 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. Staff confirmed that they have been issued with a copy of the GSCCC [General Social Care Council’s Code Of Conduct] booklet. Service users are protected by the homes recruitment practices. Training records were examined, these identified a good level of training provision, which included, NVQ,s, Health and Safety, Manual Handling, First aid, Dementia Care, Mental Health Awareness, Fire Safety, Infection Control, adult protection and Food Hygiene. Staff confirmed this when spoken with. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 23 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home and are confident their views underpin all self monitoring review and development of the home. Service users rights and best interests are not fully safeguarded by the homes record keeping in relation to Regulation 37. The health and safety and welfare of service users are promoted and protected. EVIDENCE: The registered manager is currently working to achieve the NVQ 4, Registered Managers award. Most staff, have achieved NVQ2 OR 3. Evidence was seen of certificates within staff files. Quality assurance systems have been implemented in the form of a service user questionnaire. Residents meetings have taken place and minutes of these were seen. Staff meetings minutes were examined for January and March 06. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 24 There was evidence within the care plans and training records that equality and diversity is promoted and staff spoken with said they had undertaken training in this topic. Care plans were stored securely. The manager had not informed CSCI without delay, of some incidents, identified through a complaint made to Social services and others identified through examination of care plans at the inspection. [See Standard 23]. The incidents should have been notified under Regulation 37. The following records were examined: Portable appliance testing, Fire safety, Gas safety, Maintenance records, Electric circuit test certificates and Accident records, all were satisfactory. Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 3 X 2 3 X Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 26 NO 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 YA24 Regulation 16[2][a] Requirement The Registered Person must ensure that service users are provided with adequate furniture, suitable to the service users needs. Ensure CSCI is notified for all events as specified under Regulation 37 Timescale for action 07/11/06 2 YA41 37 07/09/06 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. 6 Refer to Standard YA6 YA19 Good Practice Recommendations Care plans should contain up to date information in relation to monitoring and evaluation of how care needs are being met. Improve the documentation in relation to the input by staff and professional’s continence, sexual health and dietary needs for the individual identified. Ensure the risk assessment for the service user who self medicates is replaced. Consult with the Environmental Health Officer in relation to ongoing monitoring of systems for the prevention of legionella, surface temperatures of radiators and water DS0000002301.V306904.R01.S.doc Version 5.2 Page 27 YA20 YA24 Kingsbury House Care Home 7 9 YA26 YA30 outlet tests Provide support for service users to maintain cleanliness of their rooms. Eradicate the mal odour in the area identified at the inspection Kingsbury House Care Home DS0000002301.V306904.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park 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 DS0000002301.V306904.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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