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Inspection on 26/10/07 for Kingsfield Care Centre

Also see our care home review for Kingsfield Care Centre for more information

This inspection was carried out on 26th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

All the residents who were spoken to during this visit were positive about the way in which staff provided care and support to them. It was evident from some of the comments that staff listened to residents about how they wanted to be supported. One resident said, "The staff are very good. I like to be independent, but if I need them, they come. I have no problem talking to staff if I have a concern." The comments made by residents in the surveys, were also highly complimentary about the service. When the question `Do staff listen and act on what you say`, one resident responded, "Without a doubt".Discussions took place with a large number of residents and their families, and comments included the following: "Everything is good here. The staff are good with me- very nice and polite". "Cook makes the meal to suit me" "Senior staff are good, they listen". Relatives said: "The staff try to provide activities to stimulate people, and the way they attend to personal care is good, they are discrete. It is the best home I have been in, and I looked at over 15. They listen here and help you, and if there`s anything that bothers me I call into the office straight away, they listen and respond immediately". "The food is excellent, there`s always food and drinks available and the staff work hard to maintain the dignity of the residents." Staff were observed in positive communication with residents, and from discussion with the staff team, it was evident that they had a good awareness and knowledge of individual needs. Training is prioritised in the home, and all staff confirmed that they had access to ongoing training and development opportunities. Some residents were aware of the complaints procedure, and all residents and families who were spoken to during this visit expressed confidence in raising any concerns to the staff or manager. It was evident from these discussions that the manager responded positively to any complaints raised. The environment is maintained to a high standard and the general hygiene and maintenance of the home was very good. All residents who were spoken to praised the staff for the high standards of cleanliness in the home. The organisation has made sure that improvements made in the home are beneficial for the residents living there, Good use of external areas has been made to ensure that residents can access a safe and pleasant area to enjoy the seasons.

What has improved since the last inspection?

The organisation has a designated person to co-ordinate any allegations of abuse, and has produced a leaflet which explains the process in the event of any allegation of abuse. There has been ongoing improvements made to the fabric of the building which ensures that it is maintained to a high standard, so that residents can benefit from and enjoy pleasant living surroundings. A new addition to the facilities in the home is a relaxation therapy room, providing an additional resource for staff to introduce residents to. The staff continue to develop the social and leisure activity programme, so that a wide range of activities are available to residents living in the home.

What the care home could do better:

No requirements or recommendations have been made following this inspection.

CARE HOMES FOR OLDER PEOPLE Kingsfield Care Centre Union Road Ashton-under-Lyne Tameside OL6 9JF Lead Inspector Ann Connolly Unannounced Inspection 26th October 2007 12:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsfield Care Centre Address Union Road Ashton-under-Lyne Tameside OL6 9JF 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) 0161 330 1853 Meridian Healthcare Ltd Rita Shockledge Care Home 52 Category(ies) of Dementia - over 65 years of age (48), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (48), Old age, not falling within any other category (52), Physical disability over 65 years of age (18), Sensory Impairment over 65 years of age (2) Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 52 OP up to 48 DE (E) up to 48 MD (E) up to 18 PD (E) and up to 2 SI (E). 14th September 2006 Date of last inspection Brief Description of the Service: Kingsfield Care Centre is a single storey, purpose built, detached property set in its own grounds. It offers accommodation for up to 54 older people, in single rooms. Kingsfield Care Centre is near the town centre of Ashton under Lyne and, consequently, has good access to public transport facilities. There are also parking facilities in the vicinity. Kingsfield Care Centre has two lounge/dining rooms and one small lounge, which is a dedicated smoking area, and a quiet room. The building also has a conservatory area off the main lounge and a patio area in the inner garden. Kingsfield Care Centre is run by Meridian Healthcare Limited, which also runs several other care homes in the area. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 26 October 2007 at 12:00 During the site visit a selection of records, care plans, policies and procedures were examined. Discussions took place with the manager, staff working in the home, and some relatives who were visiting. Prior to the inspection, questionnaires were sent out to the people who live in the home, asking them to comment on how the home is run and managed, and for their views about how the staff supported them. Some of these were retuned and the comments have been included in this report. Several residents living in the home were spoken to in private during the visit, and discussions took place with them to find out what they thought about the home and what they felt about how the staff supported them. Before the inspection, we also asked the manager of the service to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This is one of the ways that we get information from the manager of the service about how they are meeting outcomes for people using their service. Information that was provided in the AQAA for this service was detailed and comprehensive and provided evidence of a service that was committed to focusing on positive outcomes for the people who use the service. Since the last inspection visit, which took place on 14 September 2006, the Commission for Social Care Inspection has received one concern about this service. There was evidence during this visit that the manager was managing complaints well, and that procedures were followed appropriately Over the last twelve months the home’s manager has received several complaints, and information in the AQAA states that these were investigated within 28 days. A number of these complaints were upheld. Fees for this home range from £361.75 to £424.34. What the service does well: All the residents who were spoken to during this visit were positive about the way in which staff provided care and support to them. It was evident from some of the comments that staff listened to residents about how they wanted to be supported. One resident said, “The staff are very good. I like to be independent, but if I need them, they come. I have no problem talking to staff if I have a concern.” The comments made by residents in the surveys, were also highly complimentary about the service. When the question ‘Do staff listen and act on what you say’, one resident responded, “Without a doubt”. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 6 Discussions took place with a large number of residents and their families, and comments included the following: “Everything is good here. The staff are good with me- very nice and polite”. “Cook makes the meal to suit me” “Senior staff are good, they listen”. Relatives said: “The staff try to provide activities to stimulate people, and the way they attend to personal care is good, they are discrete. It is the best home I have been in, and I looked at over 15. They listen here and help you, and if there’s anything that bothers me I call into the office straight away, they listen and respond immediately”. “The food is excellent, there’s always food and drinks available and the staff work hard to maintain the dignity of the residents.” Staff were observed in positive communication with residents, and from discussion with the staff team, it was evident that they had a good awareness and knowledge of individual needs. Training is prioritised in the home, and all staff confirmed that they had access to ongoing training and development opportunities. Some residents were aware of the complaints procedure, and all residents and families who were spoken to during this visit expressed confidence in raising any concerns to the staff or manager. It was evident from these discussions that the manager responded positively to any complaints raised. The environment is maintained to a high standard and the general hygiene and maintenance of the home was very good. All residents who were spoken to praised the staff for the high standards of cleanliness in the home. The organisation has made sure that improvements made in the home are beneficial for the residents living there, Good use of external areas has been made to ensure that residents can access a safe and pleasant area to enjoy the seasons. What has improved since the last inspection? The organisation has a designated person to co-ordinate any allegations of abuse, and has produced a leaflet which explains the process in the event of any allegation of abuse. There has been ongoing improvements made to the fabric of the building which ensures that it is maintained to a high standard, so that residents can benefit from and enjoy pleasant living surroundings. A new addition to the Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 7 facilities in the home is a relaxation therapy room, providing an additional resource for staff to introduce residents to. The staff continue to develop the social and leisure activity programme, so that a wide range of activities are available to residents living in the home. 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. The summary of this inspection report can be made available in other formats on request. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are given sufficient information about the home to help them in making a decision about their care arrangement. Residents’ needs are assessed prior to admission to the home so they are confident their needs will be met, and the home is sure it can meet their personal needs. EVIDENCE: Four of the residents’ files were examined during this visit. All of these files had an assessment undertaken by an appropriate professional before moving into the home. A member of staff from the home also completed an assessment of needs on any prospective resident. This information was collated so that staff in the home could be confident that they had the right skill mix to meet the needs of the individual. On completion of the assessment, the manager provided all prospective residents with a letter confirming that they were able to offer a place and that they were confident that they could meet individual needs. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 10 In each file, there was a signed copy of the home’s terms and conditions. Kingsfield does not provide intermediate care. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provided full details of residents care needs and the interventions required to meet needs. EVIDENCE: Care plans take an holistic view of the individual care needs. The care plans included a resident questionnaire, which enables staff to obtain background information about previous lifestyle, hobbies and family connections, in order to build up a life history picture. The care plan and assessment are written in a way that involves the resident, and asks questions of the residents about how they want to be supported with their care needs. Care plans include risk assessments to ensure that any hazards are identified, and strategies and interventions are put into place to minimise any risks. Moving and handling assessments, pressure sore prevention and nutritional risk assessments are included in all the care plans and assessments. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 12 There was documentary evidence that the care plans were reviewed at regular intervals. This process was used as an opportunity to identify any significant changes in care and support needs, and the care plan was amended appropriately. Emphasis was placed on involving the resident to participate in the review process, and where possible, their signature was included to demonstrate this. Where an individual was unable to sign, a representative had done so on their behalf. There was documentary evidence that residents had appropriate access to the full range of medical services available in the community. During this visit, some residents were seen to receive visits from a medical practitioner. One resident said that she only had to ask for a doctor if she needed one, and one of the staff would facilitate this for her. Staff who were spoken to had a good understanding of the care planning process, right through from assessment stage, through to implementation of the care plan. Through discussions with staff, it was evident that they had a good knowledge of individual care needs, and of the care and support that was required to meet individual needs. Daily recordings were maintained, however, the information recorded was minimal in some cases, and did not make reference or links to specific care needs as detailed in the care plan. Through discussion with the manager, it was evident that this shortfall had already been identified and fully discussed in a staff meeting held on 23rd October 2007. Minutes from the meeting demonstrated that staff were made aware of the importance of accurate recording and the discussion was also linked to the Mental Capacity Act and re-inforced to carers their own accountability in ensuring that recordings demonstrate that residents are offered choices. The home uses a pre-dispensed monitored dosage system. Medication administration records (MAR) presented as predominately appropriately maintained. However, some of the stock levels of medication did not balance with the written records. It seems that stock balances are not always carried forward and added to the receipt of monthly medication received into the home. This shortfall was addressed at the time of inspection, and the manager added the requirement to check stock levels of all medication on to the audit which she carries out monthly. This will ensure that when the monthly audit takes place, the manager and senior staff will be able to track medication and provide a full audit trail for all medication received into the home. This will minimise any risks, and ensure that medication is handled safely. Soon after this visit, the manager provided written confirmation to the Commission, that all medication had been fully audited. During this visit, staff were observed in positive interaction with residents. Residents said that staff were very good, and indicated that they were always treated with respect. One resident said, “ I have no complaints here, the food Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 13 is good and the staff are great. It’s all very nice, you can have visitors when you want”. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in a manner that supports residents to live a lifestyle that reflects their social, cultural, religious and recreational interests and needs. EVIDENCE: There was evidence during this visit of a wide range of recreational activities being made available to residents in the home. One visitor was complimentary about the staff and management and the effort they put into arranging activities and outings. Comments included, “ Staff try to provide activities to stimulate people”. It was noted that staff seemed to spend a lot of one to one time with individual residents, and activities such as board games were going on at the time of this visit. During this visit a meal was sampled. This was well presented and tasty. Residents at the table spoke highly of the home in general, and said that they always enjoyed their meals. The mealtime was relaxing and sociable. There was good interaction between staff and residents and staff were seen to treat residents with respect, speaking to them in a courteous manner. Residents were offered a choice of scampi, boiled fish or eggs with accompanying Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 15 vegetables. The desert included a range of alternatives such as ice cream, yogurts, or fruit. Staff took time to consult with residents as to their meal preferences. The general atmosphere was very pleasant, and there was evidence of staff being flexible in their approach and of them listening and responding positively to the requests made by residents. Residents and visitors confirmed that visiting arrangement were flexible. One relative said that she visited often and felt welcome at all times. She added, “ Staff are very helpful, and they keep everything up to standard, and I feel confident in approaching them with any concerns”. Residents who were spoken to indicated that the home offered a flexible lifestyle saying that they could come and go as they pleased. There was evidence that residents were encouraged to maintain control over their lives. One resident said, “ The staff are very good. I like to be as independent as possible, but if I need them, they come. I have no problems in telling someone if I have a concern, and I do my own tablets”. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place so that residents and relative can raise concerns, and so that the health, safety and well being of residents is protected. EVIDENCE: There is a comprehensive complaints procedure in place, and this information is included in the Statement of Purpose and Service User Guide. This ensures that residents have the necessary information to assist them in the event of having to make a complaint. Not all residents were aware of the complaint procedure, however, all of them expressed confidence in being able to raise a concern directly with the staff team or the manager. One resident said, I don’t need to complain because I like everything here, but if I did, I would tell the staff”. Information provided by the manager in thee self assessment document called the Annual Quality Assurance Assessment (AQAA), states that the home has received 12 complaints in the last 12 months. Information provided by the manager indicates that all complaints were responded to within the timescale of 28 days. Four of the complaints were upheld and action was taken to resolve the issues of concern. The Commission have received one concern about this service, but evidence was available during this visit to show that the manager was managing it appropriately. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 17 From discussion with residents, the staff and the manager, there appeared to be an open approach to complaints, and to responding promptly. One member of staff said it was important to listen to residents, “After all, it is their home”. Records of complaints described the nature of the complaint, the action taken and response to the complainant. Some of the concerns raised were of a minor nature, but all of them had been taken seriously, demonstrating a commitment by the manager and staff team to listen carefully and respond appropriately to concerns raised by residents and their families. There are policies and procedures in place for safeguarding adults, and staff spoken to said they had received training in adult protection procedures. Some staff had a greater understanding of the procedures than others, however, it was evident from discussion with the manager that training in safeguarding was ongoing, and that the staff supervision sessions were used to re-in force policies and procedures, and good practice in the area of safeguarding. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is appropriately maintained, decorated and cleaned to ensure that residents are provided with a safe, pleasant and hygienic environment. EVIDENCE: This was an unannounced visit to the home. As part of the visit, a tour of the building took place. All communal areas and bedrooms were found to be cleaned to a high standard. Information provided by the manager in the AQAA stated that all staff have received training in infection control and that protective clothing was provided and used by staff. This was also evidenced during this visit. The manager provided documentation confirming that all health and safety checks had been carried out in the environment and on equipment as required. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 19 There was evidence of an ongoing rolling programme of decoration and refurbishment. The newly decorated areas and furnishings were of a high standard, providing a pleasant environment for residents and visitors. Two bedrooms had been fitted with an en-suite shower facility. A new lounge for relaxing had been created, and new fire doors had been fitted throughout the home. The external patio areas had thoughtfully been designed to provide an extremely pleasant and safe external area for residents to enjoy all year round, making good use of the external space. There was evidence that bedrooms had been personalised with personal effects and furnishings. All residents spoken to and visitors at the time of the visit were highly complimentary of the standards in the home. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a well-trained staff team, and are protected by robust recruitment procedures. EVIDENCE: At the time of this visit, there appeared to be sufficient numbers of staff on duty to meet the needs of residents in the home. There was a relaxed atmosphere and staff appeared organised with their duties. Staff were seen spending quality time with residents and responding to their personal needs appropriately. Staff present during this visit included the manager, a senior member of staff, five care staff, two domestics, two kitchen staff and a laundry assistant. A selection of staff files were examined, including the file of a recently recruited member of staff. All files examined contained appropriate paperwork and Criminal Record Bureau checks and two written references. An employment history was also included on the files. Staff files included details of training, and staff who were spoken to said that there were ongoing opportunities for training. This was also evident from the training records maintained in the home. Staff also confirmed that they received a period of induction prior to commencing work. A newly recruited Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 21 member of staff was present during this visit, and was ‘shadowing’ a more experienced member of staff as part of her induction. It was evident from the comments from residents that the staff team were highly regarded. Comments included, “ Staff here are really nice”. “The staff are good with me, so nice and polite”. One relative said, “Staff are very helpful and keep me in touch with what’s going on”. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This service is run in the best interests of the residents and the management ensure that the safety and welfare of residents and staff is promoted. EVIDENCE: The manager holds appropriate qualifications and has the management experience to ensure that the health, safety and well being of residents is promoted. From discussion with residents and staff, it was evident that the manager operated an ‘open door’ policy, and welcomes discussion about ways in which the service can be developed to improve outcomes for residents living there. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 23 Meridian Healthcare Ltd had established appropriate and clear lines of accountability between the home and the rest of the organisation. The home has structured Quality Audit and Quality Monitoring systems, in addition to the less formal means of establishing the views of residents living in the home. There was documentary evidence to demonstrate that regular meetings were held with residents and their relatives. The recordings of the meetings showed that residents were consulted about all aspects of the day to day running of the home. Staff who were spoken to confirmed that they were in receipt of ongoing supervision, and supervision records supported this, Information provided by the manager in the AQAA provided evidence that policies, procedures and systems were in place to ensure that the safety and welfare of residents was promoted. Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kingsfield Care Centre DS0000005573.V349578.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!