Inspection on 25/01/07 for Kingsfield Care Home

This inspection was carried out on 25th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 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 09/07/2008.

CARE HOME ADULTS 18-65 Kingsfield Care Home 23 High Street Clay Cross Chesterfield Derbyshire S45 9DX Lead Inspector Rose Veale Unannounced Inspection 25th January 2007 09:00 Kingsfield Care Home DS0000063894.V328502.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.V328502.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.V328502.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 Vacancy Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th April 2006 Brief Description of the Service: Kingsfield provides personal care and accommodation for up to 9 adults with learning disabilities. The home is located in the village of Clay Cross, near 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. The fees at the home are £338.19 per week. This information was given by the provider on 25/01/07. Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and took place over 7 hours. The inspection visit focused on assessing compliance to requirements made at the previous inspection and on assessing all the key standards. There were 8 residents accommodated in the home on the day of the inspection. Residents and staff were spoken with during the visit. Discussions took place with the provider / responsible individual. Records were examined, including care records, staff records, maintenance, and health and safety records. A tour of the building was carried out. It was found that the registered manager had been absent from the home for approximately one month prior to this inspection visit. The responsible individual confirmed that the registered manager would not be returning and that the acting deputy manager would be the acting manager until a new manager was recruited. What the service does well: What has improved since the last inspection? What they could do better: There continued to be a reactive and disorganised approach to the management of the home so that residents’ rights, choices, safety and welfare were not fully promoted or protected. The home remained in need of general upgrading and refurbishing to ensure a more pleasant and safe environment for residents. There was no evidence of a planned approach to renewing the décor and furnishings. Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 6 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.V328502.R01.S.doc Version 5.2 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.V328502.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment information was sufficient to ensure that residents’ needs could be met at the home. EVIDENCE: The care records of 3 residents were examined, including one resident admitted to the home since the last inspection. All the records included assessment information from Social Services and, in some records, from previous care settings where the resident had lived, and from community learning disabilities nurses. The records also included an assessment made by the manager or deputy manager of the home. Of the 3 records examined, and 3 other records checked, only 1 had an up to date care plan that covered all the resident’s needs and had been reviewed in the last 12 months. (See following section – Individual Needs and Choices). Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There was a continuing lack of adequate care plans and risk assessments so it was not clear that residents’ needs and choices were agreed and fully met at the home. EVIDENCE: In the care records seen, care plans were missing, incomplete and had not been reviewed regularly. There were no care plans produced by the home for 2 residents, although there were care plans in place produced by the social services care manager / social worker. There appeared to be a reliance on using the care plans by social services staff instead of the home developing a care plan in consultation with the resident / their representative to give specific details of the service provided by the home, the action required by staff at the home to meet residents needs and choices, and the preferences of residents regarding the support provided. 1 record seen was of a resident who had spent some time in a different care setting and had then returned to the home in the summer of 2006. There was Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 10 no new assessment or care plan following the readmission. The ‘old’ care plan was in the records and had not been reviewed or updated since May 2005. There was a social services care plan in place with a note from the home’s registered manager for staff to read and act upon it. This care plan was not wholly relevant as it related to the resident living in the community with domiciliary support. There was also a new social services care plan in place relating to the resident’s readmission to the home and, again, it appeared that there was a reliance on using this plan rather than the home producing one. 1 care plan seen had not been reviewed or updated after the resident had undergone a surgical procedure requiring specific aftercare. The care plan had not been reviewed since 2004. 1 care plan seen had not been reviewed since September 2005. 1 care plan seen had been produced following requirements made at the previous inspection. This care plan covered the resident’s assessed needs, had clear details of the action to be taken by staff to meet those needs, and included the resident’s preferences regarding the daily routines. The plan had been produced in June 2006. It was discussed with the provider and acting manager that this care plan would be a good example to follow in producing care plans for other residents. There was no evidence that residents were involved in care planning at the home. Residents and / or their representatives were involved in reviews held by social services. The above issues with care plans had been raised at previous inspections and very limited action had been taken by the home in response to requirements made. Information about advocacy services was available to residents and some residents had advocates involved in supporting them. Concerns had been raised that there was a lack of co-operation by the home when advocates tried to arrange meetings with residents. There was evidence from discussion with residents and staff that residents were supported to make decisions about their lives. For example, managing personal money with support, and attending local adult education classes. Risk assessments were missing, incomplete and not regularly reviewed. The risk assessments in place for 1 service user were from the previous care setting. Risk assessments for 1 resident had not been reviewed since 2004, and for another resident not since 2005. Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents had opportunities to take part in activities both within the home and in the community so that the lifestyle offered at the home generally met their expectations. EVIDENCE: All of the residents attended day centres and / or adult education classes during the week. Residents spoken with said they liked watching television and listening to music at home. They said they had been out for meals, to a local snooker centre, to the cinema, and shopping. Residents talked about a holiday they had enjoyed in 2006 and were looking forward to going away again. Staff spoken with said that additional staff were provided to allow for planned trips out. It was noted that although the home’s vehicle was available to take residents out, it was not being used. This was said to be because 1 member of staff who could drive it was unsure whether the insurance was valid for them, Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 12 and another member of staff who could drive it had not tried it yet and was waiting for an opportunity to ‘practise’. Residents were using taxis when they went out. The provider said that the taxis were paid for from the home’s transport budget and not directly from residents’ personal spending money. Because of the lack of updated information and detail in care plans, it was not clear what activities residents wanted to take part in. There was no evidence that residents had been consulted about their social interests and what activities they would like to do. Details of residents’ family members were noted in their records. Residents spoke of recent visits to and from family members. Residents’ bedrooms seen included photographs of family and friends. Staff spoken with were clear about residents’ rights to personal and sexual relationships and were aware of the possible safeguarding issues involved. Residents spoken with said they could get up and go to bed when they liked, though they had to be up in time when attending a day centre. It was observed that residents appeared comfortable and settled at the home, and that there were good relationships between residents and staff. Residents said they helped with domestic tasks, such as setting the table and clearing away, assisting with the preparation of snacks and drinks, and cleaning their rooms. The menu for the home was decided each week and the shopping planned accordingly. One member of staff was responsible for planning the menu and said that residents were consulted about what they would like. The main meal was usually homemade, including fresh vegetables. Fresh fruit was available to residents. A choice was available if residents did not want the main menu. It was observed that residents had a choice of food at lunchtime on the day of the inspection visit. Residents spoken with said they liked the food provided. There were ample stocks of food in the home; in fact more food than could reasonably be consumed by 8 residents. The main weekly shopping had been carried out ‘on-line’ by the provider for several weeks prior to the inspection visit. There appeared to be no system in place for the effective management of food stocks to prevent over ordering. Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 13 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. Although residents’ healthcare needs generally appeared to be addressed, the lack of adequate care planning made it unclear that residents’ needs and preferences were agreed and fully met at the home. EVIDENCE: The care records seen included details of the input of healthcare professionals, such as GP, chiropodist, dentist, optician, and hospital consultants. The records appeared up to date. Concerns had been raised that residents had sometimes missed appointments and had not always been promptly referred for treatment for healthcare problems. The assessment information about residents included details of how they preferred personal care to be carried out. However, as care plans were missing, lacking in detail and not regularly reviewed, it was not apparent that residents’ needs and preferences were being taken into account, (see Individual Needs and Choices section). From discussion with residents and staff, and from observation, it was clear that staff were knowledgeable about the preferences of residents. Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 14 There were satisfactory systems in place for the storage and safe handling of medication. Since the last inspection, the home had obtained a copy of the Royal Pharmaceutical Society guidance for the administration of medication, and had improved the records kept of medication received into the home. All staff had received appropriate training about safe administration of medication. Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 15 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. There were systems in place and satisfactory staff awareness so that residents were safe guarded and their complaints listened to. EVIDENCE: The home had a complaints procedure in place that was provided in a suitable format for residents. Most residents spoken with were aware they could complain and said they would talk to staff about any concerns or problems. One resident said they had not received a service user guide or complaints procedure. Records of complaints were kept with details of the action taken and the outcome. No formal complaints had been received by CSCI since the last inspection, although concerns had been raised as noted in this report. All staff had received appropriate training in the safeguarding of vulnerable adults. Staff training records showed that this training had been carried out in 2004 and there had been no updates provided since then. Staff spoken with were aware of the procedures to follow if abuse was suspected. Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. Although it was comfortable and homely, the home remained in need of general upgrading and refurbishing so that residents would have a more pleasant and safe environment. EVIDENCE: A tour of the building was carried out, including most of the bedrooms, the communal areas, the bathrooms, laundry and kitchen. An extension to the home was being built and this was planned to provide 2 additional bedrooms, new office and laundry facilities, and a conservatory. Since the last inspection, two bedrooms had been redecorated. There were several items requiring attention, some of them outstanding from previous inspections. The ground floor toilet had peeling wallpaper and paint and the floor tiles were lifting. There was a hole in the laundry flooring, creating a potential trip hazard. A bathroom on the first floor had cracked and broken tiles to the bath surround. One bedroom on the first floor had no curtains. One bedroom had an ill-fitting window where the resident had tried Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 17 to stop the draughts with tissue paper. Most areas in the home required general redecoration and refurbishment as the décor, carpets and furniture were worn and ‘tired’. There was no programme in place to improve the décor, fixtures and fittings, although the acting manager had made a list of items required. It was discussed with the provider that some of the work needed to upgrade the home could reasonably wait until the current building work was completed, though it was not clear when this would be. Items that needed more urgent attention have been included as requirements in this report. The home appeared clean and was free from offensive odours on the day of the inspection. The standard of cleanliness appeared to have improved since the last inspection. Staff spoken with said that a new cleaner was to start soon, working on 2 days per week. Residents spoken with were pleased with their bedrooms. The bedrooms seen were personalised with residents’ photographs and possessions. One resident had been involved in choosing the colour scheme when the room was redecorated. Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 18 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, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment procedures were not sufficiently robust to ensure residents were fully protected. The staff training programme was generally sufficient so that were supported by competent staff. EVIDENCE: The records of 2 members of staff were seen. The records included all the required information, except for a recent photograph. The home was planning to employ 2 new members of staff and their records were seen. Although both had completed an application form, neither had included a full employment history and there was no evidence that this had been explored at interview. The acting manager had no experience or training in interviewing prospective staff and had not had the direct support of the provider when interviewing. The provider and acting manager were not fully aware of the requirements regarding Criminal Record Bureau disclosures when employing new staff. There was no evidence of a annual training and development plan for the home. Staff training records seen showed that staff had received training as required, such as first aid, food hygiene, manual handling, fire safety, administration of medication, and the safeguarding of vulnerable adults. There Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 19 was no evidence that night staff had received fire safety training twice a year as required by the fire officer in a report from 2005, and as required in the previous inspection report. The safeguarding adults training had taken place in 2004 and there was no evidence of any updates since then. There was some evidence of training specific to the needs of residents, such as training about epilepsy, and about challenging behaviour. Of the 8 care assistants employed, 7 had achieved NVQ Level 2. The staff rotas were seen and staffing levels discussed with residents and staff. Residents appeared satisfied with the staffing levels and described staff being available to take them out socially or to appointments. Staff said that staffing levels were adequate to meet residents’ needs and that additional staffing was provided for trips out or if a resident needed to attend an appointment. It was observed during the inspection visit that staff had sufficient time during the day to support residents in an unhurried way, and to spend time talking with residents. Staff at the home had all worked there for at least a year and appeared committed to the residents. Staff spoken with said the staff team worked well together and supported each other. Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 20 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 poor. This judgement has been made using available evidence including a visit to this service. There continued to be a reactive and disorganised approach to the management of the home so that residents’ rights, safety and welfare were not fully promoted or protected. EVIDENCE: Concerns had been raised about the absence of the registered manager. The staff rotas seen showed that the registered manager had been off sick for most of November and then at the home for one day per week during December 2006. The registered manager had not been at the home since 28th December 2006. It appeared from discussion with staff and from records seen that the registered manager had not been fulfilling management responsibilities, such as ensuring care plans were up to date, carrying out staff supervision, and ensuring the smooth day to day running of the home. Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 21 The situation was discussed with the responsible individual who confirmed in writing on the day of the inspection visit that the registered manager would not be returning and gave details of the proposed management arrangements. The management arrangements were that there would be an acting manager on a temporary basis until a new manager could be recruited. There was evidence that the responsible individual was making efforts to recruit a new manager. The acting manager was a care assistant at the home who had approximately 2 years experience. The acting manager had achieved NVQ Level 2, though not Level 3 which is more appropriate to a supervisory role. Although an experienced and competent carer, the acting manager had no experience of management responsibilities, such as interviews for new staff, and managing a budget. The acting manager had little knowledge of the relevant National Minimum Standards and regulations. The proposed support for the acting manager was from appropriately experienced people and appeared to be mainly by telephone. There was some practical support proposed from the responsible individual who had been visiting the home usually one day per week over the last 2 months. It was not clear whether the provider would be visiting the home more frequently to give direct support to the acting manager. It was discussed with the acting manager and responsible individual that the acting manager would need supernumerary time to fulfil managerial responsibilities. This could only be achieved by providing additional staff to cover the care hours worked by the acting manager, allowing time for ‘office’ work. There was no formal quality assurance system or annual development plan at the home. This was a requirement at previous inspections and there was no evidence that any action had been taken. There was no evidence that the responsible individual had carried out monthly visits and reports as required under Regulation 26. The fire safety records showed that weekly tests of the fire alarms had been carried out up to date. It was recorded that fire drills had taken place every 6 months, though there was no record of the staff that had taken part, or of how the fire drill had been carried out. Maintenance records sampled were satisfactory. It was found that the fire door at the top of the stairs was wedged open as the magnetic catch was not working. This was unsafe as the door was designed to be held back by the magnetic catch and then close when the fire alarm was activated. The wedge was removed on the day of the inspection visit and the responsible individual was made aware that the magnetic catch was not working. Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 22 Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 23 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 2 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 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 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 1 X 1 X X 2 X Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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)(2) Requirement Each resident must have a care plan that details how his or her assessed needs are to be met at the home. The care plan must be produced in consultation with residents, (or their representatives), and must be reviewed regularly. Original timescale 01/09/05 Residents must be consulted about their social interests and arrangements made to enable them to engage in local social and community activities. Original timescale 01/08/05 The laundry floor covering must be made safe so that it is not a hazard to residents and staff. The broken tiles around the bath in the first floor bathroom must be made safe to ensure there is no risk of injury to residents using the bath. Curtains, or a suitable alternative, must be provided in the identified DS0000063894.V328502.R01.S.doc Timescale for action 28/02/07 2. YA14 16(2)(m) 28/02/07 3. YA24 13(4) 08/02/07 4. YA24 13(4)(a)(b) 08/02/07 5. YA24 16(2)(c) 08/02/07 Kingsfield Care Home Version 5.2 Page 25 6. YA24 23(2)(b) 7. YA24 23(4)(c)(iv) 8. YA33 18(1)(a) 9. 10. YA34 YA39 19(1)(b) 24(1)(2) 11. YA39 26(2)(3)(4)(5) 12. YA42 23(4)(d) bedroom to ensure the resident’s privacy and comfort. The window in the identified bedroom must be repaired or replaced to eliminate drafts and ensure the resident’s comfort. The magnetic catch to the fire door at the top of the stairs must be in working order to ensure the safety of residents and staff. There must be enough care staff on duty to allow the acting manager sufficient time for the effective management of the home. Staff records must include a recent photograph. Residents, (and / or their representatives), must be involved in a system for evaluating the quality of services provided at the home. Original timescale 31/03/06 The registered provider must make unannounced visits to the home at least once a month, including the items specified in the regulation, to assess the standard of the service provided to residents. All staff working during the night at the home must receive fire safety training twice a year to ensure the safety of residents and staff. Original timescale 30/09/06 28/02/07 28/02/07 28/02/07 31/03/07 31/03/07 28/02/07 31/03/07 Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. 8. Refer to Standard YA6 YA7 YA9 Good Practice Recommendations Care plans should be reviewed at least every year, or when there is a change in the condition or circumstances of the resident. Residents should be actively encouraged and supported to use advocacy services so they have access to independent help and advice. There should be individual risk assessments in place - such as for residents who smoke, or those who use the kitchen or laundry – to ensure the safety of residents. Arrangements should be made to ensure the home’s vehicle has drivers available to take residents out. There should be a system in place to ensure the effective management of food stocks to prevent over ordering. Staff should have updates every year about safeguarding adults issues, awareness and procedures to follow where abuse is suspected. 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 residents. Records of fire drills should include the names of staff involved, details of the procedures followed and necessary action to address any problems. YA14 YA17 YA23 YA35 YA42 Kingsfield Care Home DS0000063894.V328502.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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.V328502.R01.S.doc Version 5.2 Page 28 - 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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