Inspection on 26/02/04 for Kingscourt Nursing Home

Care Home For Older PeopleKingscourt Nursing Home12 Newton Lane Hoole Chester Cheshire CH2 3RBAnnounced Inspection26th February 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Kingscourt Nursing Home Address 12 Newton Lane, Hoole, Chester, Cheshire, CH2 3RB Email Address Name of registered provider(s)/Company (if applicable) Brookaid Limited Name of registered manager (if applicable) Mrs Ann Evans Type of registration Care Home No. of places registered (if applicable) 37 Tel No: 01244 313201 Fax No: 01244 350133Category(ies) of registration, with (number of places) Old age, not falling within any other category (37) Registration number F010000181 Date First registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30th July 2002 YES NO 1/10/03 If Yes Refer to Part CKingscourt Nursing HomePage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 326th February 2004 08:30 am Wendy SmithID Code098537Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different NA perspective to the inspection process Name of Specialist (e.g. NA Interpreter/Signer) (if applicable) Name of Establishment Representative at Ann Evans the time of inspectionKingscourt Nursing HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration (if applicable) Lay Assessors Summary (where applicable) Providers Response Providers comments Action Plan Providers AgreementKingscourt Nursing HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of Kingscourt Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Kingscourt Nursing HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Kingscourt Nursing Home is a purpose built property situated in its own grounds on the outskirts of Chester city centre and close to the local amenities of Hoole shopping centre. It is served by local public transport. Bedroom accommodation is provided on three floors. There are 37 single rooms, 20 of which have en-suite facilities. Day space consists of a large lounge and a dining room with a conservatory leading off. There is a passenger lift serving all floors. WCs and assisted bathing facilities are provided on all floors. The home accommodates 37 older people, of whom 25 may be in receipt of nursing care. Care staff and trained nurses are on duty 24 hours a day, and catering and domestic staff are employed during the day.Kingscourt Nursing HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns. This inspection was carried out on 26th February 2004 and a number of the National Minimum Standards were examined. Those standards not inspected during this inspection were assessed as met at the previous inspection. Some requirements from the previous inspection remain outstanding and these are repeated within this report. These mainly relate to the staffing and management issues and statutory visits by the registered person under Regulation 26. Time was spent in conversation with the manager, service users and their relatives, and members of staff at the home. The inspection was carried out using a process of case tracking, examining the documentation of identified service users and following the delivery of care and support to them. Choice of Home (Standards 1 to 6) Two standards were assessed and one was met. The home does not provide intermediate care. The home provides information in a statement of purpose, but service users do not have a service users guide to the home. Personal and Health Care (Standards 7 to 11) Two standards were assessed and one was met. Service users have a comprehensive plan of care which provided evidence that the health and personal needs of service users were met by the homes staff with input from medical professionals being accessed as needed. There was no evidence that all medicines are checked into, and out of, the home. Daily Life and Social Activities (Standards 12 to 15) Three standards were assessed and two were met. Service users spoken with expressed their satisfaction with daily living routines and with their meals. A programme of social activities and opportunities needs to be developed. Complaints and Protection (Standards 16 to 18) Two standards were assessed and one was met. The home has policies and procedures for dealing with complaints and for the protection of vulnerable people. All staff must receive training regarding abuse. Environment (Standards 19 to 26) Five standards were assessed and three were met. The home provides comfortable accommodation and all bedrooms are single. The home was found to be clean and well-maintained. Hot water temperatures should be tested on a regular basis.Staffing (Standards 27 to 30) Four standards were assessed and were not met. Kingscourt Nursing Home Page 6 The number of care staff on duty complied with existing agreements, however the inspector remains concerned that the trained member of staff on duty at the busiest time of day is required to deal with office duties in addition to nursing and supervisory responsibilities. There was no evidence of staff induction to meet the standard, and staff files did not contain all of the required information. Management and Administration (Standards 31 to 38) Seven standards were assessed and one was met. The atmosphere of the home was positive and cheerful. There are a number of outstanding requirements regarding management issues, i.e. the introduction of a Quality Assurance system and staff supervision, and the manager needs to have adequate supernumerary time in order to implement these. There were no Regulation 26 reports from the registered provider available. Records did not provide evidence that all equipment was regularly serviced and maintained.Kingscourt Nursing HomePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action The registered person must undertake CRB checks for all existing staff. New staff employed at the home must undergo all appropriate checks as detailed in the identified 31/12/03 regulation and schedule and copies of any relevant information must be kept in the homes records. The registered person must develop an 31/1/04 effective quality assurance and quality monitoring system. The registered person must implement a formal supervision programme for staff. 31/12/03219 OP29 Schedule 2424 (1)(2)(3) 5 18 (2)OP33OP36626OP37The responsible individual must ensure that 30/11/03 monthly unannounced visits are carried out by a responsible individual, in accordance with Regulation 26 and provide copies of the reports to the National Care Standards Commission. The registered person must consult service 30/11/03 users about the programme of activities arranged by the care home and provide facilities for recreation. The registered person must make arrangements, by training staff or by other measures, to prevent service users being 31/12/03 harmed or suffering abuse or being placed at risk of harm or abuse. The registered person must ensure that unnecessary risks to the health or safety of 31/10/03 service users are identified and so far as possible eliminated. Page 8816.2.nOP12913.6OP181013.4.cOP25Kingscourt Nursing Home 1118.1.aOP27The registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users.31/10/031218.1.cOP30The registered person must ensure that 31/10/03 persons employed receive training appropriate to the work they are to perform.RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 4 5 OP26 OP23 The registered person should provide a sluicing disinfector. If single bedrooms do not have 10sq m usable floor space, the registered provider should provide additional communal space for private use. The registered person should ensure that 50 of care staff achieve NVQ level 2 by 2005.6OP28CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). NoneMet (Yes / No)Kingscourt Nursing HomePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 5 OP1 The registered person must produce a service users guide to the home and supply a 30/4/04 copy to each service user. The registered person must make arrangements for the recording, safekeeping 31/3/04 and disposal of medicines received into the care home. The registered person must consult service users about the programme of activities 31/3/04 arranged by the care home and provide facilities for recreation. The registered person must make arrangements, by training staff or by other measures, to prevent service users being 31/3/04 harmed or suffering abuse or being placed at risk of harm or abuse. The registered person must ensure that heating suitable for service users is provided 31/3/04 in all parts of the care home. The registered person must ensure that unnecessary risks to the health or safety of 26/2/04 service users are identified and so far as possible eliminated.213(2)OP9316.2.nOP12413.6OP18523(2)(p)613.4.cOP25Kingscourt Nursing HomePage 10 718.1.aOP27The registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the care 26/2/04 home in such numbers as are appropriate for the health and welfare of service users. The registered person must undertake all appropriate checks as detailed in the identified regulation and schedule and copies 31/3/04 of any relevant information must be kept in the homes records. The registered person must ensure that persons employed receive training 31/3/04 appropriate to the work they are to perform. The registered person must develop and implement an effective quality assurance and 30/6/04 quality monitoring system. The registered person must implement a 30/4/04 formal supervision programme for care staff. The registered person must ensure that monthly unannounced visits are carried out in accordance with Regulation 26, and provide 26/2/04 copies of the reports to the National Care Standards Commission and the home manager. The registered person must maintain a record of any furniture brought into the home by a service user. 31/3/04819 OP29 Schedule 2918.1.cOP301024 (1)(2)(3) 18 (2)OP3311OP361226OP371317(2) Schedule 4 23(2)cOP3714OP38The registered person must ensure that equipment provided at the care home is 31/3/04 maintained in good working order. The registered person must make suitable arrangements to prevent the spread of 30/4/04 infection.1513(3)OP38Kingscourt Nursing HomePage 11 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * 1 2 3 OP26 OP28 OP31 The registered person should provide a sluicing disinfector. The registered person should ensure that 50 of care staff achieve NVQ level 2 by 2005. The registered person should ensure that the manager attains a management qualification by 2005. The registered person should adopt suitable accounting and financial procedures to demonstrate current financial viability and to ensure that there is effective and efficient management of the home.4OP34* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Kingscourt Nursing HomePage 12 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES NO YES YES YES YES NO NO YES NO YES NO YES YES YES NO NO YES NO YES 4 2 8 NO NO YES YES 22 10 26/2/04 08:30 5Kingscourt Nursing HomePage 13 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Kingscourt Nursing HomePage 14 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) 375 To (£) 450Any charges for extras If yes, please state what the extras are:YESHairdressing, Chiropody, Newspapers, Taxi fares 2 Key findings/Evidence Standard met? The home has a statement of purpose which contains the information detailed in Schedule 1 of the Care Homes Regulations. During the inspection, written information about the home was given to two people who called to view the home. At the time of the inspection, service users did not have a copy of a service users guide as detailed in Regulation 5. See Requirement 1.Kingscourt Nursing HomePage 15 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? Each service user has a contract of terms and conditions. A copy of this contract was examined and contained the information listed in standard 2.2.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? st This standard was met at the announced inspection on October 1 2003 and was not assessed on this visit.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? st This standard was met at the announced inspection on October 1 2003 and was not assessed on this visit.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? st This standard was met at the announced inspection on October 1 2003 and was not assessed on this visit.Kingscourt Nursing HomePage 16 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Kingscourt does not provide intermediate care.Kingscourt Nursing HomePage 17 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? Each service user has a plan of care. Care plans relating to five service users were examined. Care plans were based on a full assessment of the individual and set out the action to be taken to meet the needs of service users. Reviews had been carried out on a monthly basis. There was evidence, in the form of signatures, that service users and/or their relatives were involved in the writing of the care plan. Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes)X X0 Key findings/Evidence Standard met? This standard was met at the announced inspection on October 1st 2003 and was not assessed on this visit.Kingscourt Nursing HomePage 18 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? The home does not have a medicine room. Medication in current use is kept in a secure trolley in the dining room. Additional items are stored in locked cupboards in the ground floor corridor, and the controlled drugs cupboard is in the managers office. At the time of the inspection, no service users were administering their own medication, however policies and procedures are in place to cover self-medication. Records did not demonstrate that medicines are always checked in to the home, and this is made more difficult as medication administration sheets are received four-weekly from the pharmacy, but the drugs, which are dispensed in `Nomad format, are received weekly. Records of drugs returned to the pharmacy were not available for inspection. There were occasional omitted signatures on administration records See Requirement 2 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? st This standard was met at the announced inspection on October 1 2003 and was not assessed on this visit.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? st This standard was met at the announced inspection on October 1 2003 and was not assessed on this visit.Kingscourt Nursing HomePage 19 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 2 Key findings/Evidence Standard met? The home is run in an informal manner, with flexibility to suit the preferences of service users. The home does not have an activities organiser and a record of activities, which is kept in the main lounge, showed that some social activities are organised by care staff, but not on a regular or planned basis. See Requirement 3 The home has visits from three different church groups. Two of these visit monthly and one visits weekly. There are also visits from the mobile library. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 0 Key findings/Evidence Standard met? This standard was met at the announced inspection on October 1st 2003 and was not assessed on this visit.Kingscourt Nursing HomePage 20 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? At the time of the inspection, the registered person acted as appointee for two service users. All others had relatives who looked after their financial affairs. The manager has used the advocacy service provided by Age Concern, however she said that she preferred to involve social services in any advocacy arrangements. Service users are encouraged to bring personal belongings into the home, and these were seen in their rooms. The manager said that if possible, some personal belongings, e.g. photographs, are brought in to the home prior to the service user being admitted to provide something familiar for service users who have been in hospital. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This standard was met at the announced inspection on October 1st 2003 and was not assessed on this visit.Kingscourt Nursing HomePage 21 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days 0 X X X X 1 X 3 Key findings/Evidence Standard met? The home has a complaints policy, and procedures for dealing with complaints. A complaints book is in place, and a copy of the complaints procedure is displayed in the entrance hall.Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? st This standard was met at the announced inspection on October 1 2003 and was not assessed on this visit.Kingscourt Nursing HomePage 22 The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA listsYES X2 Key findings/Evidence Standard met? The home has policies and procedures for the protection of vulnerable adults. The manager said that following the last inspection, she had provided training for staff regarding abuse and one of the registered nurses working on night duty had also provided training for night staff. No records of this training had been kept, therefore it was not possible to identify how many staff had received training. See Requirement 3.Kingscourt Nursing HomePage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? st This standard was met at the announced inspection on October 1 2003 and was not assessed on this visit.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? Communal space is provided on the ground floor only. There is a large main lounge and a dining room with conservatory leading off. There is also a conservatory on the front of the home which is a smoking area for service users.Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was met at the announced inspection on October 1st 2003 and was not assessed on this visit.Kingscourt Nursing HomePage 24 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? All areas of the home are accessible for service users. Handrails are fitted in the corridors. There is a passenger lift and two staircases. Various aids and adaptations were seen to be in use. A nurse call system is fitted in all areas.Kingscourt Nursing HomePage 25 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 37 23 0 0 3 34 3X X 0 0Key findings/Evidence Standard met? All service users have single bedrooms. Three rooms are smaller than the recommended 10sq.m.Kingscourt Nursing HomePage 26 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This standard was met at the announced inspection on October 1st 2003 and was not assessed on this visit.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? All bedrooms are naturally ventilated and window restrictors are in place. Radiators in communal areas and bedrooms were either low surface temperature or had appropriate covers to protect service users from injury. Radiators in bedrooms had accessible controls to regulate temperature. Some parts of the home were not very warm and had additional portable heaters, and a member of staff said that there was a problem with the heating in some areas. There was no evidence available in the home to show that heating boilers had been serviced and maintained. See Requirement 5. Hot water temperatures were not measured and recorded on a regular basis. See Requirement 6.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 2 Key findings/Evidence Standard met? A tour of the building confirmed that there was a good standard of cleanliness in the home. Domestic staff on duty were spoken with and were able to describe their routine cleaning schedules and the products used to maintain hygiene within the home. There were no obvious malodours in the home. Policies and procedures are in place for the control of infection. Sluicing facilities in the home do not meet the standard. A sluicing disinfector should be provided in homes providing nursing care. See Recommendation 1.Kingscourt Nursing HomePage 27 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 11 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence 11 14 131 9 23 11 Standard met? 2 No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 112 X X 24Kingscourt Nursing HomePage 28 Staff rotas indicated that agreed staffing levels are maintained. In four comment cards received from service users and visitors, it was commented that there were not always enough staff on duty. The manager said that she is not always able to cover for sickness and other unexpected absences. On some weekend days there is only one domestic/laundry assistant working in the home. The inspector continues to express concern that the manager, or nurse in charge, is required to cover office duties, nursing duties and supervise the care and ancillary staff, in particular during the busy weekday morning period, with no administration support. The registered person should review the staff allocation at the busiest times of the day. See Requirement 7. All staff providing personal care are over 18 years of age. There were two care staff vacancies at the time of the inspection. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 6 26 2 Key findings/Evidence Standard met? In order to meet this standard a further six members of care staff need to achieve NVQ qualification by 2005. See Recommendation 2. Domestic staff are working towards NVQ qualification.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? Staff files did not contain copies of all of the documents listed in Schedule 4 of the Care Homes Regulations, and in three of the files examined there was only one reference. There was evidence that CRB disclosures had been applied for and received for all staff. See Requirement 8.Kingscourt Nursing HomePage 29 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 1 Key findings/Evidence Standard met? The homes induction programme does not meet TOPSS specification. In conversation with staff, confirmation was given that an induction process had been undertaken, however this had been a verbal process and was not supported by written evidence of the subjects covered or the name of the person carrying out the induction. Induction records seen in staff files had not been completed. See Requirement 9, which is an outstanding requirement from the previous inspection.Kingscourt Nursing HomePage 30 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The manager is a registered nurse and has held her present position for several years. She does not have a management qualification. See Recommendation 3.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? st This standard was met at the announced inspection on October 1 2003 and was not assessed on this visit.Kingscourt Nursing HomePage 31 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 2 Key findings/Evidence Standard met? A service user survey has been carried out and the responses were available for inspection. There was evidence that some self-auditing had been introduced and this needs to be further developed in a systematic manner and incorporated into a development plan for the home. See Requirement 10.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 2 Key findings/Evidence Standard met? The home has an appropriate Employers Liability Insurance certificate. There was no business plan or financial plan available at this inspection. The manager said that all financial records are kept at the head office in Liverpool. Copies should be made available for the next inspection. See Recommendation 4.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X3 Key findings/Evidence Standard met? A number of service users have small amounts of personal money in safe-keeping at the home. Records of all transactions were kept and were double signed, and receipts were retained for any purchases made on behalf of service users. The homes staff do not handle any pensions or allowance books, however the registered person is appointee for two service users.Kingscourt Nursing HomePage 32 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 1 Key findings/Evidence Standard met? Regular supervision of care staff has not been put in place to meet this standard. See Requirement 11.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? Records required to be kept in the home, as detailed in Schedule 4 of the Care Homes Regulations, were in place, with the following exceptions: A copy of reports made by the registered person under regulation 26. See Requirement 12. A copy of personal information relating to staff employed. See Requirement 8. A record of furniture brought into the home by a service user. See Requirement 13.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? A new training programme for all staff had been devised but had not been implemented at the time of the inspection due to sickness of the senior nurse with lead responsibility for staff training. Records were not available to demonstrate that staff had received training relating to moving and handling and infection control. See Requirement 9. There was evidence of on-going fire training and catering staff had food hygiene certificates. Hazardous substances were in locked storage, and domestic staff were aware of safe working practices. PAT testing had been carried out in January 2004. There was evidence that the passenger lift was serviced twice yearly, however there were no records to demonstrate that hoists had been serviced and maintained. There were no records of boilers being serviced and maintained, and an electrical installation certificate was not available for inspection. See Requirement 14. There was no evidence that water systems had been tested for Legionella. See Requirement 15. Accident records were well maintained. There was evidence of regular testing of the fire alarm system.Kingscourt Nursing HomePage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateWendy Smith Joan DugganSignature Signature SignatureKingscourt Nursing HomePage 34 PART DLAY ASSESSORS SUMMARY(where applicable) There was no Lay Assessor at this inspection.Lay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Kingscourt Nursing HomePage 35 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 26th February 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleKingscourt Nursing HomePage 36 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary Comments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate NO NO NO NONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 20th April 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. E.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Kingscourt Nursing HomePage 37 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I Mr S Mc Hugh of Kingscourt Nursing Home confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I Mr S McHugh of Kingscourt Nursing Home am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Kingscourt Nursing HomePage 38 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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