Inspection on 09/03/06 for Kingshill

This inspection was carried out on 9th March 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kingshill 26/07/06

Kingshill 10/08/05

Kingshill 10/01/05

Kingshill 15/07/04

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

CARE HOME ADULTS 18-65 Kingshill Kingshill Court Standish Wigan Greater Manchester WN6 0AR Lead Inspector Bernard Tracey Unannounced Inspection 9th March 2006 09:30 Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 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 Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 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. Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kingshill Address Kingshill Court Standish Wigan Greater Manchester WN6 0AR 01257 421332 01257 427681 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) Making Space Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (15) Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered for a maximum of 15 service users to include:up to 15 service users in the category of Mental Disorder (MD) aged 18 - 65 years up to 15 service users in the category of Mental Disorder over 65 years (MD(E)) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 10th August 2005 2. Date of last inspection Brief Description of the Service: The company Making Space privately owns Kingshill Care Home. The Home is purpose built and provides accommodation and personal care and support for up to 15 adults whom suffer from an enduring mental illness. The Home is set in its own grounds in a residential area of Standish. Wigan and Standish town centres are easily accessible by public transport. The Home provides all single accommodation, no rooms offer en suite facilities. There is car parking to the front of the Home and enclosed, private gardens to the rear. Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a four-hour period. The home was not notified that the inspection was going to take place. This was the second inspection of the year and many standards were looked at and reported on in the Inspection report dated 10th August 2005 The following records were read; residents’ records, staff rosters, complaints received book, training records and staff files. The Inspector spoke to the three staff members on duty, the deputy manager and also spoke at length to five residents during the tour of the home. What the service does well: What has improved since the last inspection? The dining room has been redecorated. Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 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 Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Resident’s are assessed prior to admission in order to determine that their needs can be met in the home. EVIDENCE: Two care plans were examined and they both contained detailed assessments, which had been carried out prior to the resident being admitted to the home. A core assessment is completed which contains the referral information and a needs assessment is also carried out by staff from the home. A plan is then developed which contains the resident’s needs, desired outcome, how will this be achieved and by whom. The plan is reviewed monthly or more often if required and the resident is involved throughout the process. The documentation of a recent admission to the home demonstrated that a transition meeting had taken place prior to admission and all those people involved in the care had attended. Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were examined at the last inspection There is a clear and detailed care planning system in place that includes residents’ involvement and provides the staff with the information needed to meet the needs of the residents. EVIDENCE: The key standards were examined at the last inspection on the 10th August 2005. All of the key standards were met. Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were examined at the last inspection Residents are supported in acquiring new skills enabling them to live more independently through access to local community and leisure facilities. The dietary needs of the residents are well catered for with a balanced and varied selection of food available that meets the residents’ tastes and choices. EVIDENCE: The key standards were examined at the last inspection on the 10th August 2005. All of the key standards were met. Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standards were examined at the last inspection Committed, enthusiastic and well-trained care staff are meeting the physical and mental health needs of the residents. EVIDENCE: The key standards were examined at the last inspection on the 10th August 2005. All of the key standards were met. Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 The home has a good complaints system, which residents can use if they are Unhappy Systems were in place to protect residents from abuse, although a number of staff were in need of training to ensure their full understanding of the procedures. EVIDENCE: The home has a robust complaints policy and procedure in place. Examination of the home’s complaint register indicated that there had not been any complaints made to the home since the previous inspection. A resident interviewed said she would talk to her key worker, or if she wasn’t on duty, any member of staff if she had a concern or complaint. A whistle-blowing procedure was also in place and staff interviewed showed their understanding of it. It was unclear whether the policy and procedure used by the home for the Protection of Vulnerable Adults (POVA) was the recently published Wigan Interagency procedure. Members of staff spoken with did not indicate that they were aware of the new guidance and none had received training in relation to this. Examination of staff training files showed that training for all staff in adult protection had not taken place. A member of staff confirmed she was awaiting the training. Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 26 30 The standard of furnishing and fittings within the home was good, providing a homely, safe, well adapted, clean and comfortable environment for residents to live in. The residents’ bedrooms are furnished with their own belongings and display personal effects such as ornaments and photographs. EVIDENCE: A tour of the premises showed that the home is spacious, well decorated and equipped. There is a programme of routine maintenance to keep it in good order. Residents have a choice of shared spaces in which to sit and there is good access for people who use wheelchairs. The home is clean and free of unpleasant odours, making it a pleasant environment for residents and their visitors. There are landscaped gardens, which are accessible, and these provide residents with safe areas in which to walk or sit. Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 14 Five residents spoken to were very pleased with their individual rooms and said that they had “brought in a number of personal possessions to make them feel more homely”. All bedrooms are supplied with door locks. Staff have a master key, which can be used to gain access in an emergency. Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 The standards of recruitment and induction of staff are good with appropriate checks being carried out and staff demonstrating a clear understanding of their roles. At times there are insufficient staff in the home to meet the residents needs. EVIDENCE: The home has a comprehensive recruitment policy and procedure and when three staff files were checked it was evident that the home follows the procedure, and ensures the interview process, police/CRB checks, written references, health checks and past work history are all obtained and considered satisfactory before the person starts work. The home has a staff-training programme offering staff access to mandatory training and some specialist subjects linked to the needs of the residents. There is a training plan and staff are notified of the available training dates and when they are expected to attend. One staff member said that “the training here is excellent.” The company is presently undertaking recruitment to fill the posts of home manager, a second cook and a full time domestic. A deputy manager is Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 16 adequately covering the role of manager whilst the recruitment process is taking place. In the absence of the cook and domestic, support workers are expected to take on these duties thereby taking them away from their role in assisting residents. An examination of the duty rota indicated that this was happening on a frequent basis and that attempts by the deputy manager to employ Agency workers had been sporadic. An Immediate Requirement was made for the company to rectify this, followed up by telephone confirmation with the Social and Healthcare Services Manager, informing him that sufficient staff must be on duty in the home to meet the residents’ needs. As a minimum this is to include: 1 Deputy Manager 1 support worker 1 domestic and 1 cook. These staffing numbers and mix of staff must be maintained at all times during the rostered day time hours. . Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 In the absence of a manager the home is run effectively, efficiently safely and for the benefit of residents. EVIDENCE: The home has been without a Registered Manager since January 2006. Whilst the recruitment of a replacement is taking place the Deputy Manager has been nominated to manage the home. Staff spoke highly of the deputy manager saying that ‘Josie gives clear guidance on what is expected of us and is very supportive”, “she tells us if we are not doing something right and is strict but fair”. Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 18 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 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X 3 X X X X X Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 19 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 12 Requirement Timescale for action 30/04/06 2. YA33 18 3. YA37 8 All support staff and managers must be given the opportunity to receive training in the protection of vulnerable adults. Ensure that at all times there are 09/03/06 sufficient staff numbers to appropriately meet the needs of the residents. (Immediate requirement issued on the 9th March 2006) The service should employ a 30/04/06 suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kingshill DS0000005742.V268826.R01.S.doc Version 5.1 Page 21 - 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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