Inspection on 17/11/05 for Kingsfield Care Home

This inspection was carried out on 17th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kingsfield Care Home 27/05/09

Kingsfield Care Home 02/07/08

Kingsfield Care Home 21/11/07

Kingsfield Care Home 26/06/07

Kingsfield Care Home 25/01/07

Kingsfield Care Home 19/04/06

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Kingsfield Care Home 23 High Street Clay Cross Chesterfield Derbyshire S45 9DX Lead Inspector Sue Richards Unannounced Inspection 17th November 2005 10:00 Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 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 Home DS0000063894.V266068.R01.S.doc Version 5.0 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. Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kingsfield Care Home Address 23 High Street Clay Cross Chesterfield Derbyshire S45 9DX 01246 861505 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) Kingsfield Care Homes Ltd Mr Alkesh Odedra Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2005 Brief Description of the Service: Kingsfield is registered to provide personal care and accommodation for up to 9 young adults with learning disabilities. The home is located in the village of Clay Cross on the outskirts of Chesterfield close to local shops and amenities. The home is a converted domestic property with accommodation over two storeys. There are seven single bedrooms and one double bedroom, a large lounge and separate dining room. There are separate kitchen and laundry facilities of a domestic scale and a large attractive garden to the rear of the home with a small garden and car parking space to the front and side of the home. Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection, which was unannounced, was on the environment, staffing and management systems and organisation. Discussion took place with both the registered manage, the provider, care staff and some service users. A number of records were also examined in relation to the above. What the service does well: What has improved since the last inspection? What they could do better: Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 6 A systematic and proactive approach to the management of the home needs to be adopted, in order to ensure that the home properly meets with the provisions of the Care Standards Act 2000 and NMS for Younger Adults, thereby ensuring that the rights, safety, health and welfare of service users are best protected and more effectively promoted. 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. Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 EVIDENCE: At the previous inspection for this service carried out in May 2005 a requirement was identified in relation the provision of written terms and conditions for each service user. These had been provided. Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards in this section were not assessed on this occasion. EVIDENCE: Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 10 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): The standards in this section were not assessed on this occasion. EVIDENCE: Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 11 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): The standards in this section were not assessed on this occasion. EVIDENCE: Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 12 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): The standards in this section were not assessed on this occasion. EVIDENCE: Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 13 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, 27, 28, 29 & 30 Although a comfortable and homely environment is provided, it is tired and dated and there has been little recent investment in terms of the upgrading, repair and renewal of the fabric of the home. In some aspects, the safety of service users is compromised due to their being no formally recorded system of environmental risk assessment and no planned programme of maintenance, repair and renewal. EVIDENCE: A full tour of the building was carried out. This provided a homely and comfortable environment, which was relatively clean, warm and well lit, although there were some areas identified, where deep cleaning was required. The provision of hours and arrangements for domestic support in the home (by way of cleaning, cooking and laundry duties was discussed with the manager and staff. (See staffing section of this report). The inspection reports of January and May 2005 had identified the need for investment in the upgrading, repair and renewal of the home. There was no evidence of this having being undertaken and there was no identified written programme for this. Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 14 Heating radiators throughout the home, in all areas to which service users had access were extremely hot to touch. They did not provide low surface temperatures or suitable guarding/covers and posed a significant risk to service users. One bedroom had an additional freestanding electrical heater, which was hot to touch and for which there was no recorded risk assessment relating to its use. This was raised in writing during the inspection with the registered provider and identified as a serious concern with immediate action required. There was no emergency call system provided in the throughout the home. A number of bedrooms had trailing wires from sockets to various items of electrical equipment, which belonged to individual service users. Some bedrooms had furnishings with broken handles. There was no lockable storage provided in service users own rooms and a broken windowpane observed in one of the first floor single rooms. There were no recorded environmental risk assessments provided. There is one communal bathroom and one bedroom had an en suite providing bath, wc and wash hand basin. Both of these were ready for upgrading and some repairs. Carpets to these areas were in need of renewal with suitable hard floor coverings. The separate ground floor wc room was in need of repair and redecoration. All bedrooms were provided with wash hand basins. These were not all suitably equipped by means of tiled splash backs, shelving, mirrors or towel rails. Duty rotas indicated that staff provided sleep in cover at night. There were no separate staff facilities. The manager advised that the office was used. (Discussions were also held about service users needs in relation to this and the fact that there was no emergency call system). The environment does not provide for any potential service user who may have physical disabilities, for examples there are no ramps, lift etc, although existing service users are independently mobile. The Inspector also discussed with the manager the use/suitability of a ‘baby gate’ in the hallway at the bottom of the stairs. The manager advised that this was to promote the safety needs of one named service user. The laundry provided one domestic washing machine and one drying machine. The washing machine did not have a proper sluice cycle. There was no separate sluice provided. Some of the exterior window frames were in need of repair/repainting. Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 15 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): 31, 32, 33, 34, 35 & 36 Staff hours provided was not always sufficient to enable staff to properly carry out their roles and responsibilities and to meet service users needs. Records were not properly maintained in relation to staff recruitment and induction and their training and development planning. EVIDENCE: Staff duty rotas were examined, together with staff job descriptions and discussions were held with the manager, staff and service users available regarding staffing arrangements in respect of service users individual needs and dependencies. These indicated that there was not always sufficient staff hours provided, particularly in relation to domestic hours and the individual needs of service users with regard to choice of activities, particularly outside the home. The arrangements for the recruitment and selection of staff were discussed with the manager and staff and records were examined in relation to this. These were generally satisfactory, although the personal file of one carer did not contain all of the records, which are required by legislation to be kept. Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 16 The arrangements for staff induction and training were also discussed and the personal records of two care staff were examined in relation to this. These contained details of individual training undertaken by them, including NVQs. However, there was no full individual record of their induction and no individual training and development plan or overall recorded training and development plan for staff. (See the Conduct and Management section of this report). The arrangements for individual staff supervision were satisfactory. Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 17 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, 38, 39, 40, 41, 42 & 43 The lack of a systematic and proactive approach to the management of the home compromised the rights and health, safety and welfare of service users. EVIDENCE: The registered manager had achieved NVQ level 4 in management and care since the previous inspection. Staff meetings were being held at approximately 2 monthly intervals and minutes were recorded. Staff spoken with felt these to be beneficial. Residents meetings were also regularly held including those organised with external advocacy support. The most recent recorded satisfaction survey, undertaken with service users was in 2004. This was in a format suitable for service users accommodated. Matters arising included some dissatisfaction about access to staff. (See also Staffing section of this report). There was no annual development plan for the home. Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 18 A number of policies and procedures were examined in relation to areas inspected on this occasion. These were satisfactory. Key policies and procedures were also provided in suitable formats for the service users accommodated. A number of records were examined, which are required to be kept in the home. These included: Staff duty rotas Staff records, (recruitment, training and supervision). Service users monies Accidents and incidents Fire records Visitors record These were generally satisfactory, with the exception of that relating to staff records (recruitment and training/induction). Details of core health and safety training for staff were discussed with the manager and staff. Discussions with one staff member and examination of the personal files of two care staff indicated that the core health and safety training undertaken by them was up to date. However, there was no clear training record or overall training plan in place. (See staffing section of this report). The arrangements for the annual maintenance of equipment in the home were also examined. These were largely satisfactory, with the exception of the maintenance of hot and cold water systems, including Legionella prevention. This was raised in the previous inspection for this service carried out on 16.05.05. There were no recorded environmental risk assessments in place, although areas of significant/potential risk to service users were identified during the inspection of the building. (See environment section of this report). Again this has was raised in the previous inspection report for this service). The business and financial plan for the home was not requested on this occasion. An up to date certificate detailing adequate liability insurance for the home was openly displayed. Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 2 2 2 2 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 2 2 1 2 1 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kingsfield Care Home Score X X X X Standard No 37 38 39 40 41 42 43 Score 2 2 2 3 2 1 2 DS0000063894.V266068.R01.S.doc Version 5.0 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement The registered person must ensure that service users care plans, identify as to how their needs in respect of the health and welfare are to be met. (From July 2004). NB THIS WAS NOT ASSESSED ON THIS OCCASION. The registered person must enable service users to take part in age, peer and culturally appropriate activities. NB THIS WAS NOT ASSESSED ON THIS OCCASION. The registered person must consult with service users about their social interests and make arrangements to enable them to engage in local, social and community activities. NB THIS WAS NOT ASSESSED ON THIS OCCASION. Suitable guarding/covers must be provided to all heating radiators in rooms to which service users have access (or low surface temperatures ensured). This must receive immediate attention with priority for their DS0000063894.V266068.R01.S.doc Timescale for action 01/09/05 2 YA12 12, 16 01/08/05 3 YA14 12, 16 01/08/05 4 YA24 13 31/01/06 Kingsfield Care Home Version 5.0 Page 21 5 YA24 13 6 YA24 13,16,23 7 YA24 12 8 YA33 12, 18 9 YA41 17, 18 10 YA42 13 individual completion to be carried out in accordance with recorded risk assessments. Environmental risk assessments must be recorded for all areas, to which service users have access. A written itemised programme for the upgrading, repair and renewal of the home must be provided detailing proposed timescales for achievement. A copy of this must be forwarded to the Commission. The programme must include all items detailed under the Environment Section of this report. The registered person must ensure that the home is conducted in such a manner as to respect the dignity of any service user and with due regard to their disability. In this instance, a review of the use of the ‘baby gate’ with a suitable alternative solution provided, which effectively meets the needs of an adult service user. The registered persons must ensure that sufficient staff hours are provided to enable them to undertake their roles and responsibilities in accordance with their job descriptions, and to meet service users individually assessed needs. (Previous inspection report dated 16.05.05 - timescale 01.08.05). Staff records must be kept in the home in accordance with Schedules 2 & 4 of the Care Homes Regulations 2001 and including that relating to staff induction training. (From inspection report 16.05.05 timescale 01.08.05. Hot and cold water system DS0000063894.V266068.R01.S.doc 31/01/06 31/12/05 31/01/06 31/01/06 31/01/06 31/12/05 Page 22 Kingsfield Care Home Version 5.0 11 YA42 13 12 YA39 12, 24 maintenance must be undertaken (including design solutions to control the risk of Legionnella). Previous timescale – 01.05.05. This inspection – immediate requirement. Documented environmental risk 31/01/05 assessments must be recorded (safe working practise topics) and reviewed accordingly. (From inspection report 16.05.05 – timescale 01.09.05). An annual development plan 31/03/06 must be provided based on the systematic review and auditing of the home and accounting for feedback from service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA35 Good Practice Recommendations Staff training and development plans should be in place. Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Kingsfield Care Home DS0000063894.V266068.R01.S.doc Version 5.0 Page 24 - 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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