Inspection on 02/07/08 for Kingsfield Care Home

This inspection was carried out on 2nd July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 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 21/11/07

Kingsfield Care Home 26/06/07

Kingsfield Care Home 25/01/07

Kingsfield Care Home 19/04/06

Kingsfield Care Home 17/11/05

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 28/09/2008.

CARE HOME ADULTS 18-65 Kingsfield Care Home 23 High Street Clay Cross Chesterfield Derbyshire S45 9DX Lead Inspector Rose Moffatt Unannounced Inspection 2nd July 2008 09:30 Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 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.V367702.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2007 Brief Description of the Service: Kingsfield provides personal care and accommodation for up to 9 people with learning disabilities. The home is in the village of Clay Cross, near Chesterfield, close to local shops and amenities. The home is a large, detached house with accommodation over two storeys. There are seven single bedrooms, one with an en-suite bathroom, and one shared bedroom. There is a large lounge and separate dining room. There are separate kitchen and laundry facilities of a domestic scale. There is 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. Information about the home, including CSCI inspection reports, is available in the home or from the provider or manager. The fees at the home are £358 per week. The provider gave this information on 21st July 2008. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of our inspections is on outcomes for people who live in the home and their views on the service provided. The inspection process looks at the provider’s ability to meet regulatory requirements and national minimum standards. Our inspections also focus on aspects of the service that need further development. We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: • The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. • Surveys returned to us by people using the service and from other people with an interest in the service. • Information we have about how the service has managed any complaints. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. • Relevant information from other organisations. • What other people have told us about the service. We carried out an unannounced inspection visit that took place over 6.5 hours on one day. The inspection visit focused on assessing compliance to requirements made at the previous inspection and on assessing all the key standards. There were 5 people living in the home on the day of the inspection visit. People who live in the home and staff were spoken with during the visit. The registered manager was not available on the day of the inspection visit, so a telephone discussion took place with him on the following day. Some people were unable to contribute directly to the inspection process because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. ‘Case tracking’ was used during the inspection visit to look at the quality of care received by people living in the home. Two people were selected and the Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 6 quality of the care they received was assessed by speaking to them, observation, reading their records, and talking to staff. What the service does well: What has improved since the last inspection? What they could do better: Care plans could be person centred and more detailed to ensure people’s needs were properly described and to ensure their preferences and expectations were met. People were frustrated by the lack of progress on the building of the extension to the rear of the home. People did not like the unsightly rubble and safe Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 7 access to the garden was affected. The building work should be completed as soon as possible and safe access to the garden should be provided so that people can enjoy their environment. The home should be refurbished and redecorated so that people have a more pleasant environment, suitable for their needs. 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 Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a good assessment process so that people were confident the home was able to meet their needs. EVIDENCE: Four surveys were received from people living in the home. Two people said they had received enough information about the home before deciding to move in, two said they had not. Each person in the home had their own copy of the Statement of Purpose and Service User Guide. The AQAA said that introductory visits were offered to people who were considering living in the home. There were no people who had come to live in the home since the last inspection in November 2007. The records of two people were seen. Each included a range of assessment information that had been reviewed and Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 10 updated every year. The assessment information included details of the person’s history, family, hobbies and interests, social needs and preferences, as well as personal and health care needs. It appeared from observation, from talking to people living in the home, and looking at care records that their needs were met and that staff were competent to meet their needs. Two surveys were received from relatives of people living in the home, one said the person’s needs were always met, one said that needs were not fully met. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The approach to care planning was not sufficiently robust and person centred to ensure that people were fully involved and consulted about their needs and preferences. EVIDENCE: The two care plans seen covered most of the assessed needs of the person. One person had no care plans to address their social, spiritual, or nutritional needs. The care plans were not person centred and lacked detail. There were few references to how staff should ensure the person’s privacy and dignity were maintained. For one person most of their care plans had not been reviewed since 2006, and for the other person most care plans had been last reviewed in February 2007. There was little evidence that people were Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 12 involved in developing and agreeing their care plans. The care plans were not produced in appropriate formats for all people living in the home – this was recognised in the AQAA as an area for improvement. Some people needed constant supervision, as detailed in their care plans. There were concerns raised that people may be placed at risk if proposed reductions in staffing levels were made. (See Staffing section of this report). There were appropriate risk assessments in each of the care records seen. People were involved in some decision making, such as menus, holidays and outings. There were regular meetings for people living in the home. A person living in the home had chaired the most recent meeting and people had discussed whether they would like to be involved in the recruitment of staff. People also had regular meetings with an independent advocate. There was no information in the home about the Mental Capacity Act 2005 and staff had not received training about this. Four staff returned surveys and nearly all said they always had up to date information about people living in the home and relevant training to meet people’s needs. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were encouraged and supported to engage in activities in and out of the home so that the lifestyle in the home met their needs, preferences and expectations. EVIDENCE: All of the people living in the home went out to day centres or adult education classes. There was a range of social activities offered, such as shopping, going to the library, going bowling, and going out to the local snooker club. People were encouraged and supported to use local facilities. One person said “I like going to the snooker club on a Saturday night”. One person said they liked to go out for walks. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 14 A vehicle was provided for people to use, but this was being repaired on the day of the inspection visit. There were concerns that proposed reductions in staffing would limit people’s social activities and outings. (See Staffing section of this report). People living in the home said they could always decide what they wanted to do each day, during the evenings and at weekends. One person said they liked to stay up to watch TV and sometimes enjoyed a lie in at weekends. People all had keys for their bedroom doors and some had a key for the front door of the home. The AQAA said the home could do better by encouraging people to engage in voluntary or paid employment if they wished, and by encouraging people to take more responsibility for domestic chores. People had been involved in deciding the menu, and in shopping for food. One person made lunch for themselves and another person on the day of the inspection visit. People said they liked the meals. One person said they liked the Sunday roast. Staff were well aware of people’s likes and dislikes and ensured choices were available. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Medication was well managed and people were supported to access health care services so that their health care needs appeared well met. The care plans were not person centred and not sufficiently detailed to ensure that people received care to meet their individual needs and preferences. EVIDENCE: The care plans seen covered most of the person’s assessed needs and included some information about the person’s preferences, but generally lacked detail. There were few references to how staff should ensure people’s privacy and dignity were maintained. The care plans were not person centred. There were records of other healthcare professionals involved in the care and support of the person, such as GP, District Nurse, dentist, and chiropodist. Wherever possible, people were encouraged and supported to go to surgery / Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 16 clinic appointments, rather than relying on home visits. Appropriate referrals were made to specialist services, such as learning disability nurses, and audiology. The changing healthcare needs of two people were documented and some new care plans had been put in place, although some information was missing from the plans. One relative said that they were kept informed about the person’s health. One relative was not satisfied that the person’s healthcare needs were fully met at the home. Medication was stored securely in a locked cupboard. Medication Administration Records (MARs) seen were correctly completed. All staff had received appropriate training about the safe handling and administration of medication. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although their complaints were listened to, appropriate and effective action was not always taken and people were not fully protected. EVIDENCE: The complaints procedure at the home was available in a suitable format for the needs of people living there. The address given for CSCI was not correct. Complaints records were kept and showed the action taken and the outcome of all complaints or concerns raised. The concerns recorded had been reported to social services and CSCI as appropriate. Most people said they knew who to speak to if they were unhappy and they knew how to make a complaint. One person said, “I speak to my keyworker and other staff”. One relative said the home had responded appropriately to concerns raised. One relative said they felt the home had not taken their concerns seriously. Staff said they knew what to do if anyone raised concerns about the home. People had access to an independent advocacy service and were encouraged to use this. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 18 No complaints had been received by CSCI since the last inspection in November 2007. Staff had received training about safeguarding vulnerable adults. Staff spoken with were aware of the correct procedures to follow if abuse was suspected. People living in the home said they would go to staff with any concerns. There was a safeguarding vulnerable adults issue referred to social services in February 2008. The issue was not reported by the home to social services until prompted by CSCI. The issue was investigated by social services and was resolved after appropriate action was subsequently taken by the home. The personal money of people living in the home was kept securely and records were kept of all transactions. Receipts were kept for all purchases. The manager, responsible individual and the deputy managers were the only people with access to the money. Records seen had one signature for each transaction. One person’s money was checked and was short by a very small amount. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home was clean and homely. However, the lack of progress in building work and refurbishing caused frustration and potential risks to people living in the home. EVIDENCE: Since the last inspection three bedrooms had been redecorated, a new television had been provided in the lounge, and a bedroom window had been replaced as required. One person had moved to a larger bedroom and was pleased with this. They were also pleased with the redecoration of their new bedroom and said they had chosen the colours. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 20 No progress had been made in completing the extension to the rear of the home. No work had been carried out on the extension since late 2006. The building work was unsightly, with the half-built extension, rubble from a partly demolished garage, and a pile of rubble outside the lounge window. The building site was not fenced off. There was a temporary path from the patio outside the lounge window to the garden. This path was uneven and not safe for some people to use without support from staff. People said, “I would like to know when the building outside is going to be finished”, and “the building work needs sorting”. Another person said they were “fed up” with the building work. One relative said, “We would like to see the extension finished as we feel it has spoilt the pleasure of the gardens for the residents”. The lounge furniture was worn and tatty, with bits of trim missing from chairs and settees, and a split in the fabric of one settee. One person had difficulty in getting up from the settee as it was quite low. The carpet looked faded in patches, stained and very worn. There was an area where the carpet was ruckled, causing a potential trip hazard. The décor in the lounge was dated and tired. One person said the lounge carpet needed replacing as “it has had it”. One relative said the lounge could do with new seating and a new carpet. Staff said that new décor, carpets and furniture would improve the home. Staff said the home was “let down” by the state of the décor and furniture. The kitchen was clean and tidy. The kitchen units, work surfaces, and flooring were dated and worn. The dishwasher had broken down and had been removed and not replaced. The laundry was suitably equipped. There were holes and rips in the flooring that had been repaired by tape. The AQAA said the home could do better by completing the building work, and that this was planned in the next 12 months. The manager was unable to give any timescales for completion of the extension. The AQAA did not give any plans for refurbishing the interior of the home. The home was clean and free from offensive odours on the day of the inspection visit. Three people said the home was always fresh and clean, one person said it usually was. There was no cleaner employed so care assistants Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 21 carried out most of the cleaning required. People living in the home helped with some domestic tasks, such as cleaning their own rooms, helping with clearing and washing dishes, and doing their own laundry with support from the staff. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels and staff training were sufficient to meet the basic needs of people living in the home. People were protected by a satisfactory recruitment process. EVIDENCE: The staff rota showed that the usual staffing during the week was two staff in the morning up to 10am, then one staff up to 4pm, two staff for the evening up to 9pm, and one person sleeping-in. Staff said the sleep-in person was awake until everyone had gone to bed, usually about 11pm, then awake again from 6am, working until 10am. They said the sleep-in person was only occasionally awoken during the night to help people. At weekends, there were two staff on duty all day. Staff said this staffing arrangement was usually sufficient to meet the needs of people living in the home. Staff were concerned that proposed reductions in Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 23 staffing would affect the safety of people in the home and would limit the opportunities for social activities. Staff said the reduction in staffing had only recently been proposed as there were fewer people living in the home and one member of staff had just started maternity leave. This issue was discussed with the manager by telephone on the day after the inspection visit. The manager said that, wherever possible, staffing levels would remain unaltered. There was a stable staff team at the home, with most staff having worked at the home for several years. One person said that staff were “kind and caring”. Another person said “we have a laugh with the staff”. The records of two staff were seen, including one recently recruited. Nearly all the required information and documents were in place. There was no photograph yet for the recently recruited member of staff. The involvement of people living in the home in the recruitment of staff had been discussed at a recent meeting, and was also mentioned in the AQAA as an area the home could improve on. The induction programme for new staff met Skills For Care standards. Staff said their induction had covered everything they needed to know to do the job. One person said they had “a very good induction”. Staff had individual training records and had received all the required training, such as manual handling, safeguarding vulnerable adults, and fire safety. Staff said they had training that was relevant and kept them up to date. Nearly all the staff had achieved a National Vocational Qualification (NVQ) in care at level 2 or above. Staff had not received training to keep them up to date with recent legislation and guidance, such as the Mental Capacity Act 2005. The AQAA said that plans to improve the service included providing training about equal opportunities for staff, and also specialist training about the needs of people with learning disabilities. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was effective day-to-day management of the home so that people generally received a consistent and well organised service. EVIDENCE: The manager was suitably qualified and experienced to run the home. The manager was usually in the home on one or two days each week, and the responsible individual also came in for one or two days. There were two deputy managers who were both working towards NVQ Level 4 in care and hoped to achieve the qualification by January 2009. The AQAA said that it was planned for one of the deputy managers to become the registered manager in the next 12 months. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 25 The management team had worked together to make improvements in the home, such as developing the quality assurance system, ensuring staff records included all the required information, and ensuring incidents were recorded and reported to the appropriate authorities. People spoken with had confidence in the deputy managers for the day-to-day organisation and running of the home. People said they could take any concerns to the deputy managers and felt they would take appropriate action. People did not appear to have the same confidence in the manager and responsible individual. One person said that the deputy managers had responded to concerns raised “but the owners never follow through”. One person said, “We are not always informed about future plans for Kingsfield”. The response on one survey to the question ‘what could the service do better?’ was “better management”. As noted in the Environment section of this report, people were frustrated by the continued lack of progress of the building work to complete the extension to the rear of the home. As noted at previous inspections, people wanted improvements made to the dated and worn décor and furniture in the home and were disappointed that little had been done. These issues were discussed with the manager. He said that he and the responsible individual were well aware of the need for improvements to the home, but he could not give any timescale for achieving the improvements. The AQAA was completed by the manager and was returned late. Most sections of the AQAA were completed, although some information was missing from the dataset section. The information provided gave a reasonable picture of the current situation within the service. The evidence to support the comments made was satisfactory, although there were areas where more supporting evidence would have been useful to illustrate how the service was planning to improve. The deputy managers had further developed the quality assurance system. People living in the home had completed surveys in April 2008. The results had been analysed and presented in a report available to people living in the home and their relatives/ representatives. The report was professionally presented and included action to be taken in response to the findings of the surveys. The report was not available in suitable formats for all people living in the home. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 26 The deputy managers had encouraged and supported people to join in with the regular meetings, and a person living in the home to chair the meeting. People were able to air their views and ideas at the meetings. The AQAA said that all equipment and systems in the home had been serviced and maintained as required. The fire log book showed that weekly alarm tests had been carried out up to date. Also, that fire drills were carried out at least every six months. The records did not always show the people involved in the fire drill, if procedures were followed, any problems or any action to be taken arising from the fire drill. Accidents were recorded, but did not include all the information required as the records did not comply with relevant health and safety legislation. As noted in the Environment section of this report, the lounge carpet was ruckled in one area, a potential trip hazard. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 X 2 X X 2 X Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 28 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. 1 Standard YA6 Regulation 15(1) Requirement Timescale for action 30/09/08 2 YA24 3 YA24 4 YA24 5 YA24 Care plans must cover all the assessed needs of the person. This will ensure that people receive all the care and support they need. 13(4)(a)(c) The temporary path from the patio area to the garden must be made safe for people to use. This will reduce the risk of falls for people living in the home. 16(2)(c) The identified person must be provided with seating in the lounge that is suitable for their needs. This will help maintain the person’s independence and ensure their comfort. 16(2)(c) The damaged settee in the lounge must be replaced. This will ensure people living in the home are provided with adequate furniture. The carpet in the lounge must be replaced. This will reduce the risk of falls for people living in the home and improve their environment. 13(4)(c) There must be a written risk assessment of the building site with details of appropriate action taken to ensure the DS0000063894.V367702.R01.S.doc 30/08/08 30/09/08 30/11/08 11/08/08 Kingsfield Care Home Version 5.2 Page 29 safety of people living in the home. 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 YA6 Good Practice Recommendations People (or their representatives) should be involved in devising their care plans. The care plan should be available in a format that the person can understand. The care plan should be person centred. This will ensure that people’s needs and preferences are known and fully met. There should be information available in the home about the Mental Capacity Act and staff should have training to gain knowledge about the act and its implications. This will help to protect people living in the home and promote their rights. People living in the home should be actively involved in shopping for food to ensure choice and to encourage independent living skills. The records of personal money held for people living in the home should have two signatures for each transaction. Where possible, one of the signatures should be the person whose money it is. This will help to protect people. There should be a programme of refurbishment, in consultation with people living in the home, to ensure a pleasant and comfortable environment. A staff training and development programme should be developed to ensure that staff fulfil the aims of the home and are able to meet the changing needs of people living there. There should be a permanent, full-time manager with the appropriate skills and experience to ensure effective and consistent management of the home. This would ensure that the home is run in the best interests of people who live there. The quality assurance report should be available in appropriate formats for people living in the home. The quality assurance system should include seeking the views of relatives / carers / others involved in the lives of people living in the home. This will ensure a more robust system DS0000063894.V367702.R01.S.doc Version 5.2 Page 30 2 YA7 3 4 YA17 YA23 5 6 YA24 YA35 7 YA37 8 YA39 Kingsfield Care Home 9 YA42 of quality assurance so that people’s views and ideas drive improvements in the service. Accidents should be recorded in a format that complies with health and safety and data protection legislation. This will help to protect people living in the home. Kingsfield Care Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Home DS0000063894.V367702.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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