Inspection on 08/11/04 for Kingsgate

Care Home For Older PeopleKingsgate25 - 27 North Street Sheringham Norfolk NR26 8LWAnnounced Inspection8th November 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Kingsgate Address 25 - 27 North Street, Sheringham, Norfolk, NR26 8LW Email address Name of registered provider(s)/company (if applicable) Mr Anthony Churchill Mrs Jennifer Churchill, Mrs Virginia Taylor Name of registered manager (if applicable) Mrs Lynn Frost Type of registration Care Home No. of places registered (if applicable) 33 Tel No: 01263 823114 Fax No: 01263 821779Category(ies) of registration, with (number of places) Old age, not falling within any other category (33) Registration number I070000244 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30th July 2002 YES NO 22/10/03 If Yes refer to Part CKingsgatePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 38th November 2004 09:00 am Mrs Geraldine Allen Mrs Ruth HannentID Code074928Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNot applicable Mrs Ginny Taylor & Mrs Lynn FrostKingsgatePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s AgreementKingsgatePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Kingsgate. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Provider’s response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.KingsgatePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Kingsgate is a care home providing personal care and accommodation for up to 33 older people. The care home is owned by Mr A Churchill, Mrs J Churchill and Mrs V Taylor. The home is located close to the centre of the seaside town of Sheringham, close to shops, pubs and other local amenities. The home consists of a two-storey building with 27 single and 4 double rooms on the ground, first and second floors, serviced by a shaft lift. There is a variety of communal lounges and a large dining hall where other social activities can take place. There is also a paved garden area with seatingKingsgatePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTOR’S SUMMARY (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection was announced. Not all of the National Minimum Standards were inspected on this occasion and, where a standard has been inspected, the complete range of subelements, as set out in the National Minimum Standards, may not have been assessed. The score given represents those aspects viewed on the day and which are commented upon within the text of the report. Standards not assessed on this inspection will be assessed on future inspections. This inspection focused on the outcomes experienced by service users and there was ample evidence to show that service users receive an excellent quality of care in very well maintained and homely surroundings. Evidence was obtained through discussions with service users, staff and the service providers. A substantial number of comment cards were also received from service users and relatives. Records were also seen and it is noted that this home continues to move forward rapidly in respect of its compliance with current legislation and National Minimum Standards. It is particularly noted that the home is producing consistently high standards in terms of staffing levels and the training in place is both relevant and of a very good standard. The home is commended. Choice of Home (Standards 1-6) 6 of the 6 standards were assessed. All were met. Recommendations were made at the last inspection regarding the development of the service user guide and also the contracts given to service users once in the home. Both recommendations have been met. A copy of the home’s statement of purpose and service user guide, contained within a brochure, was provided at the time of inspection. This document is well laid out and provides potential service users with ample information to allow them to make an informed choice to enter the home. The layout and design of the guide element of the brochure is particularly commended. Very good records were seen relating to the pre-admission assessment process and these were stored within the individual care plan, providing continuity of information. Verbal evidence was provided of the inclusion of other health care and social care professionals being involved in the assessment process as necessary. Documentation within care plans also supported this evidence.KingsgatePage 6 Health and Personal Care (Standards 7-11) 5 of the 5 standards were assessed. Standards 8, 10 & 11 were met. Standard 9 was met in part. Standard 7 was exceeded. A recommendation was made at the last inspection regarding the development of a policy document relating to the care of service users when they are dying and at the time of death. This has been met. The home has implemented new care plan formats. These were reviewed in some detail and are regarded as very comprehensive. Each care plan was signed by the service user to indicate their involvement and agreement with the plan. The plans also contained full details of each review and any interventions by healthcare professionals. All relevant risk assessments were also in place. The recording within the care plans was of a good standard. The home is commended. Deficiencies regarding the dispensing of medicines were discussed with Mrs Taylor and she undertook to ensure these were dealt with without delay. A requirement has been made in regard to the issues discussed. There was substantial anecdotal evidence, obtained from service users, staff and in responses in comment cards, to demonstrate this home provides care in a way that protects the privacy and dignity of service users. Daily Life and Social Activities (Standards 12-15) 4 of the 4 standards were assessed. All were met. A recommendation was made at the last inspection regarding choices available at mealtimes. Service users spoken to confirmed they were offered choices of food and the general comments regarding food were positive and complimentary. Those requiring assistance with their food were also satisfied. Comments made by service users on the day of inspection and through completed comment cards, showed that they were satisfied with daily life and routines at the home. All felt they were treated with respect and that their privacy was respected by staff. All relatives/significant others who completed comment cards confirmed they were able to visit the service user at any time. There was evidence that service users are able to develop and maintain good links with the local community. Expressions to this effect are also contained within the home’s brochure. Complaints and Protection (Standards 16-18) 3 of the 3 standards were assessed. All were met. A requirement was made at the last inspection regarding restrictions placed upon service users. Documentary evidence was seen to show that this had been met. A recommendation was also made at the last inspection regarding the updating of a policy in relation to adult protection. This was updated in December 2003. A copy of the home’s complaints procedure is included in the brochure and is also displayed around the home. It appeared generally well known to service users and visitors to the home. There was ample anecdotal evidence from service users and staff to demonstrate service users rights were protected. Environment (Standards 19-26) Kingsgate Page 7 7 of the 8 standards were assessed. All those standards assessed were met. Standard 22 was not assessed. A requirement was made at the last inspection regarding hot radiators. The remedial action taken was described. Risk assessments have also been put in place as required. A letter from Environmental Health to the CSCI confirmed that thermostatic mixing valves have been fitted. Recommendations were also made at the last inspection regarding bathing facilities and locks on doors. Both have been met. All service users were asked if they would like a lock fitted to their door and provision was made for locks to be fitted as requested. This facility is offered to all service users on entering the home. This is a comfortable home with very good accommodation for service users. Rooms are quite large and many have en-suite facilities. Bedrooms were seen to be highly personalised, comfortable and warm. All rooms have ample natural light and ventilation. The home was clean, tidy and free from odours. The environment appeared in a good state of décor and repair. Staffing (Standards 27-30) 2 of the 4 standards were assessed. Standard 30 was met and standard 27 exceeded. A requirement was made at the last inspection regarding the General Social Care Council Code of Conduct. This was discussed with Mrs Taylor, who confirmed that copies of the code of conduct are given to all staff, together with a copy of the home’s own statement on this matter. A recommendation was also made at the last inspection regarding induction and foundation training in line with the National Training Organisation guidelines. The home is now using ManorCourt induction and foundation training. One of the senior care staff with delegated responsibility for the completion of the training records showed the inspector the records for the most recently appointed staff. These were up to date and appropriately completed. The provision of staff hours is excellent in this Home and standard 27 was exceeded. The home is commended. Management and Administration (Standards 31-38) 5 Of the 8 standards were assessed. Standards 33, 36, 37 & 38 were met. Standard 32 was exceeded. A requirement was made at the last inspection regarding the inclusion of copies of birth certificates on staff files. Whilst this requirement has not been met in full, Mrs Taylor confirmed that most are now in place and the few outstanding will be received shortly. Details of the last quality assurance audit were seen within the home’s brochure. Statements regarding the regular use of questionnaires to assess service users views were also seen. There was evidence that the service providers are endeavouring to obtain the views of all interested parties and make clear undertakings to respond appropriately to any views expressed. Service users were seen raising issues with Mrs Taylor about food and the response was immediate and appropriate. This demonstrated that service users felt able to express their views and know they would be taken seriouslyKingsgatePage 8 Various health and safety records were seen during this inspection. Accident, fire and COSHH records were all up to date and well written. Records showed that all fire systems were on regular servicing contracts. During the course of this inspection it was noted that care staff were entering the kitchen without wearing protective clothing over their uniforms. It is recommended that protective clothing is provided for when staff need to enter the kitchen.KingsgatePage 9 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for action NoneAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard NoneCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). NoneMet (Yes / No)KingsgatePage 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action The Registered Person ensures that: 1. Medication Administration Records are only signed once the member of staff dispensing the medicine has witnessed With its ingestion. immediate effect. 2. The correct codes for nonadministration are used. 3. The quantity of dispensed liquid medicine is properly checked.113 (2)OP9RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Refer to Good Practice Recommendations Standard *KingsgatePage 11 1OP38It is recommended that staff should be provided with protective clothing to wear over their uniforms whilst in the kitchen.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.KingsgatePage 12 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire • Records • Care plans / Care pathways • Meals • Activities • Other (Specify) ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others feedback Visiting professionals feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES NO NO NO YES NO YES NO YES YES NO YES YES YES NO YES 8 10 1 NO NO YES YES 19 0 8/11/04 9.30 7.00KingsgatePage 13 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable.KingsgatePage 14 Choice of HomeThe intended outcomes for the following set of standards are: • • • • • • Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home.Standard 1 (1.1 – 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users’ guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the home’s service user’s guide. Range of fees charged From (£) 315.00 To (£) 400.00Any charges for extras If yes, please state what the extra’s are: Key findings/Evidence This standard was met.YES CHIROPODY, HAIRDRESSING, NEWSPAPERS, TOILETRIES 3 Standard met?KingsgatePage 15 Standard 2 (2.1 – 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? This standard was met.Standard 3 (3.1 – 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? This standard was met.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? This standard was met.Standard 5 (5.1 – 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? This standard was met.KingsgatePage 16 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This home does not provide intermediate care.KingsgatePage 17 Health and Personal CareThe intended outcomes for the following set of standards are: • • • • • The service user’s health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect.Standard 7 (7.1 – 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 4 Key findings/Evidence Standard met? This standard was exceeded.Standard 8 (8.1 – 8.13) The registered person promotes and maintains service users’ health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence This standard was met. 1 0 Standard met? 3KingsgatePage 18 Standard 9 (9.1 – 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 1 Key findings/Evidence Standard Met? A member of staff was observed dispensing medicines at lunch time. It was noted that the member of staff was signing the medication administration record to say the medicine had been taken before the service user had ingested the medicine. It was also noted that the quantity of liquid medicines being dispensed was not being checked carefully. The medicine administration records were also seen and it was noted that the reasons for nonadministration were not being clearly recorded. Standard 10 (10.1 – 10.7) The arrangements for health and personal care ensure that service users’ privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? This standard was met.Standard 11 (11.1 – 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? This standard was met.KingsgatePage 19 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: • • • • Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them.Standard 12 (12.1 – 12.4) The routines of daily living and activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. 3 Key findings/Evidence Standard met? This standard was met.Standard 13 (13.1 – 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users’ preferences. 3 Key findings/Evidence Standard met? This standard was met.Standard 14 (14.1 – 14.5) The registered person conducts the home so as to maximise service users’ capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? This standard was met.KingsgatePage 20 Standard 15 (15.1 – 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? This standard was met.KingsgatePage 21 Complaints and ProtectionThe intended outcomes for the following set of standards are: • • • Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse.Standard 16 (16.1 – 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence This standard was met. 0 0 0 0 0 0 0 3Standard met?Standard 17 (17.1 – 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? This standard was met.KingsgatePage 22 Standard 18 (18.1 – 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence This standard was met. Standard met? YES 0 3KingsgatePage 23 EnvironmentThe intended outcomes for the following set of standards are: • • • • • • • • Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic.Standard 19 (19.1 – 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users’ individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? This standard was met.Standard 20. (20.1 – 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users’ private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? This standard was met.Standard 21 (21.1 – 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? This standard was met.KingsgatePage 24 Standard 22 (22.1 – 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard did not form part of this inspection.KingsgatePage 25 Standard 23 (23.1 – 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence This standard was met. NO YES NO 0 0 0 0 Standard met? 3 X XX X X XKingsgatePage 26 Standard 24 (24.1 – 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? This standard was met.Standard 25 (25.1 – 25 8) The heating, lighting, water supply and ventilation of service users’ accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? This standard was met.Standard 26 (26.1 – 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? This standard was met.KingsgatePage 27 StaffingThe intended outcomes for the following set of standards are: • • • • Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 – 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence This standard was exceeded. X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X0 20 6 Standard met? 4KingsgatePage 28 Standard 28 (28.1 – 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence This standard did not form part of this inspection. 6 30 Standard met? 0Standard 29 (29.1 – 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard did not form part of this inspection.Standard 30 (30.1 – 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? This standard was met.KingsgatePage 29 Management and AdministrationThe intended outcomes for the following set of standards are: • • • • • • • • Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 – 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met? This standard did not form part of this inspection.Standard 32 (32.1 – 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 4 Key findings/Evidence Standard met? This standard was exceeded.Standard 33 (33.1 – 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? This standard was met.KingsgatePage 30 Standard 34 (34.1 – 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard did not form part of this inspection.Standard 35 (35.1 – 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence This standard did not form part of this inspection. Standard met? 0 X X XStandard 36 (36.1 – 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 3 Key findings/Evidence Standard met? This standard was met.KingsgatePage 31 Standard 37 (37.1 – 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? This standard was met.Standard 38 (38.1 – 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? This standard was met.KingsgatePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSYES Condition Compliance The home is to be conducted as a care home in the category of older people (OP). Comments Evidence was gained through examining records and through discussion with service users and staff to show this condition was complied with.Condition Compliance The home may accommodate a maximum of 33 service users.YESComments Records and observations showed there were 28 service users residing at the home on the day of the inspection.Condition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateGeraldine Allen Ruth Hannent Roger HadinghamSignature Signature SignatureKingsgatePage 33 Public reports It should be noted that all CSCI inspection reports are public documents.KingsgatePage 34 PART DD.1PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 8th November 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleKingsgatePage 35 Action taken by the CSCI in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan by 11th January 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. D.2 Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here KingsgatePage 36 D.3PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Mrs V Taylor of Kingsgate confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Mrs V Taylor of Kingsgate am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.KingsgatePage 37 Kingsgate / 8th November 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000027278.V188583.R01© This report may only be used in its entirety. 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