Inspection on 29/06/07 for Kingsleigh House

This inspection was carried out on 29th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kingsleigh House 14/10/09

Kingsleigh House 02/11/05

Kingsleigh House 08/06/05

Kingsleigh House 29/11/04

Similar services:

Westmead

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

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

CARE HOMES FOR OLDER PEOPLE Kingsleigh House 37 Harbinger Road Kings Norton Birmingham West Midlands B38 0AD Lead Inspector Rachel McGorman Key Unannounced Inspection 29th June 2007 09:30 X10015.doc Version 1.40 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 Kingsleigh House DS0000018461.V336916.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 Older People. 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. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsleigh House Address 37 Harbinger Road Kings Norton Birmingham West Midlands B38 0AD 0121 459 9995 0121 451 2868 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) Olivet@cch-uk.com Christadelphian Care Homes Mrs Pauline Bateman Care Home 29 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (30) Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Home may also accommodate two named persons under 65 years of age, one with a physical disability and one with a learning disability Bedroom 23 on the first floor will be subject to the following restriction: The admission of any service user to that room must be discussed with the NCSC prior to arrangements being made. 2nd November 2005 Date of last inspection Brief Description of the Service: Kingsleigh House is registered to provide residential care for up to 30 older people of the Christadelphian faith who are active, who may have a physical disability or who may experience mental health problems. The home may also accommodate two named persons under the age of sixtyfive years, one with a physical disability and one with a learning disability. Respite care can be provided when a room is available and day care can also be made available. The range of fees varies from £362 - £520 per week. Kingsleigh House is owned and run by Christadelphian Care Homes, (formerly Bethany Guild which was formed in 1943), and is a registered charity. The home is administered by a Board of Trustees, with the assistance of an Administrator and the local Home Committee. Situated on the borders of Worcestershire and on the edge of Birmingham, Kingsleigh House is a purpose built, two storey building which also incorporates a sheltered housing unit for more independent older people. The stated aim of Kingsleigh House is to provide care and support in safe, warm and comfortable surroundings where residents, relieved of the many pressures of life, can maintain a high standard of dignity, and can enjoy a good quality of life in the company of those who share their faith, hopes and values. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine key inspection, was to monitor the care provided at the home, to assess how well the service meets the needs of the people who live there, in relation to the stated aims and objectives, and to follow up previous requirements and recommendations. Preparation for the inspection included viewing previous reports, and documents relating to the home, and considering the various contacts made with the home since the last inspection. The Annual Quality Assurance Assessment (AQAA), has been submitted to the Commission. This is a detailed self-assessment document that provides updated information about the establishment, and how well the stated aims and objectives are being met. The visit was unannounced and took approximately five hours, when some time was spent with service users, discussing with them what it is like living at the home, and observing their interactions with staff. The care records of three residents were checked in detail for case tracking purposes, and the Medication Administration Records were also seen. Discussions were held with relatives and visitors to the home at the time of the inspection. During conversations with staff, comments were made about what it is like to work at Kingsleigh House, and two staff files were viewed. Discussions were held with the Care Manager, Mrs Paula Bateman and the deputy about their respective roles, and the day-to-day management of the home. A tour of the premises was undertaken, and the ongoing maintenance and redecoration of the house was discussed. The records relating to the servicing of equipment, and to health and safety matters were also seen. The various improvements that have been implemented and the future proposals for the development of the home were also considered. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 6 What the service does well: A warm welcome is given on arrival at Kingsleigh House, and there is a calm and relaxed atmosphere, where mutual respect and consideration are constantly in evidence. Relevant information about the service, and what can be provided, is available to assist prospective residents and their families to make the right decisions about their future care needs. A high standard of personal care is provided for each resident at the home, and the staff work well with other professionals and agencies, to help to improve and maintain the health of each person, with obvious benefit to them. The policies and procedures relating to the administration of medication and the training provided for staff, help to ensure that residents are protected. The support of families and friends of residents, and their involvement with the home is encouraged, which contributes to the wellbeing of the people who use the service. Residents confirmed that they are fully involved in making decisions about their daily lives, that they are treated with respect and consideration at all times, and that their privacy was observed by staff at the home. The care provided at the home revolves around the people who live there, and their needs are understood and met in an appropriate way. Opportunities are available for everyone living at the home to do the things they enjoy, and they are also able to choose to be involved in the activities that are provided, if this is their wish. The arrangements regarding the provision of food reflect the individual likes and dislikes and the preferences of each service user, and the provision of a wholesome diet will help to maintain the health and wellbeing of service users. The complaints procedure is clear and concise, and enables any concerns to be expressed. A record is also maintained of all the comments made about the home, which helps to give a balanced view of the service that is being provided. The building is maintained to a high standard, and everywhere is fresh and clean. The house gives the appearance of being well cared for, and it is nicely furnished, warm and comfortable, and safe and secure. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 7 Residents live in a homely, comfortable and safe environment, where their privacy and dignity is respected, and their independence promoted, and with their personal possessions around them. Residents benefit from the satisfactory employment procedures that are implemented at the home and they are supported by an effective staff team who are appropriately trained and supervised. The quality of the service provided at the home is checked to make sure that the home achieves what it says it will for the people who live there, and to enable them to say how they would like the service to develop. A professional, organised approach is evident from the management, who create an open and supportive environment with benefit to both residents and staff. What has improved since the last inspection? A more detailed and thorough assessment is now undertaken prior to a prospective service user being admitted, which helps to determine if the needs of the person can be met at the home. The introduction of a dedicated activities organiser to develop the programme of activities for residents, has provided further opportunities for them, and should help to increase their enjoyment of life. The ongoing development of the premises has further enhanced the facilities available to the people who live and work at the home. The progressive approach by the management of the home and the commitment of the staff ensures that the service continues to improve. The further development of the quality monitoring system, is helping to produce the best possible outcomes for service users, and to measure how well the aims and objectives of the home are being met. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 8 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. The summary of this inspection report can be made available in other formats on request. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. 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. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The information available to prospective residents, gives them the information they need about the home, and the care that can be provided, to help them to make an informed decision about their future care. The pre-admission assessment provides relevant details about the prospective resident, to ensure that the home is able to meet their identified personal and healthcare needs. All service users belong to the Christadelphian Community, and have chosen to live in the home because of their personal beliefs. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 11 EVIDENCE: A Statement of Purpose and a Service Users Guide are produced and provide extensive information for prospective residents and their family or representative, about the home and the care that can be provided, to enable them to make an informed decision about their future care needs. Further details about the home are included in Guidance Notes for Residents, and a signature is required from the manager, and the resident or their representative to confirm their agreement and acceptance, and this then forms the basis for a signed contract at the end of the agreed trial period. These documents are regularly reviewed, and the information is updated to ensure that they give an accurate description of the service that can be provided, and to help people decide if the home can meet their specific needs. The admission procedure recognises the need for a sensitive approach to be taken to the assessment process and to the introduction to residential care for a prospective resident, although, in practice many people who are referred are familiar with the home, from their previous involvement with the local church. The assessment process has been reviewed and a very detailed checklist, that includes every aspect of the prospective persons care, is now completed. The outcome is then scored to accurately determine their precise needs, and to confirm if the home is likely to be able to meet those needs. The Care Manager or Deputy usually undertakes a pre admission assessment following the initial referral, and a visit to Kingsleigh House is encouraged. The prospective resident is invited to spend time with the resident group and to have a meal. Arrangements may also be made for a short stay, if this is preferable, prior to a decision being made about future care needs. The first eight weeks are considered to be a trial period, during which time the resident is able to decide if they are likely to be happy living at the home, and also the staff are able to further assess if they are can meet the needs of the resident. In addition a Community Care Assessment is obtained from the placing authority, prior to admission, for people who are not self-funding. The detailed information contained in the care files, and discussions with staff residents, confirmed that the appropriate procedures are followed, that their needs are being met, and that they are living at the home because this is their wish. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. 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. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service users plan of care is based on the initial assessment, which clearly identifies their assessed needs, and how these will be met. Risk assessments are completed, to support people to be as independent as possible. The health and personal care needs of residents are well documented, and support is provided by staff in a way that respects their wishes, and their privacy and dignity. The policy and procedures covering the administration of medication ensure the protection of service users. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 13 EVIDENCE: The care plans provide evidence that the personal and healthcare needs of residents are being met. An individual plan of care is developed with each person, and is based on the initial assessment undertaken during the admission process. This document is very comprehensive and covers all the aspects of care in relation to the daily living needs of the service user. The individual plans of care for three residents were examined in detail, and evidence seen of further developments in the process. Monthly reviews are completed regularly, and the content of the care plans is detailed and informative. The involvement of the resident and their family or representative is also encouraged and recorded, and the document is signed whenever possible to indicate the agreement of the resident. Risk assessments are completed, in respect of mobility, moving and handling, and tissue viability, and also other activities such as ironing and using a kettle. Relevant documentation was seen in each care plan and the many activities of daily living for each individual were also recorded. A clear profile of the specific needs of each person was gained from these records, and how staff respond to them. The care plans seen during the inspection, clearly indicate that the health care needs of the people who live at the home are monitored closely and that relevant action is taken. The home is well supported by the Primary Health Care Team, and referrals are made when necessary, for example to the continence advisor. Specialist treatment can be accessed as needed, and the advice of the district nurses is sought when necessary. There are some resident who require regular attention with dressings to leg ulcers. The Medication Administration Records were seen during the inspection, and had been completed to a satisfactory standard. A monitored dosage system is in place at the home and is being implemented appropriately. Records show that regular medication reviews are undertaken by the GP, and that training is provided for staff on the administration of medication. The Pharmacist Inspector had been involved previously with the home, in regard to the lack of support and advice from the suppliers, but the inspector was told that the situation has since been resolved. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 14 Evidence to indicate that residents are treated with dignity and respect was observed in the interactions of staff with them, and was also confirmed in discussions with several people during the visit. The comments were all very positive about everything at the home, and it was obvious that people were here because they wanted to be, and were very content. The following remarks were made by residents: • • • • • • • • • • • This is a lovely place We are well cared for here I like my room They always respect my wishes I take part in all the activities There’s always something to do I can do what I wish here They listen to me I can always see the doctor I have a lovely view from my room The home is always clean and fresh Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. 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. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The social and emotional needs of residents are identified, and various recreational opportunities provided to ensure their interests are fulfilled. The wishes and preferences of each person are respected, and they are encouraged to make choices about all the activities of daily living, and to have as much control over their lives as they are able. The people who live at the home have complete freedom in regard to their contacts, both within and outside the home, which enables a good quality of life to be maintained. Residents are offered a choice of nutritious, wholesome and well-balanced meals that helps in maintaining their health and wellbeing. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 16 EVIDENCE: Residents living at Kingsleigh House have complete freedom of choice in regard to their contacts, both within and outside the home, and they are enabled to make choices with regard to all the activities of daily living, for example, when to get up or go to bed, and how to spend their day, or whether to join in the various pastimes. This was confirmed in conversation with service users and staff, and also in comments from visitors. The spiritual needs of residents are paramount at Kingsleigh House, and the commitment of residents at the home to the Christadelphian faith gives a sense of common purpose and belonging. The periods of Bible Study and Worship are said to be a very important aspect of daily life and a Bible reading is usually held each evening. Service users are also able to attend the local church situated in the grounds of the home. The social, cultural and recreational needs of each person are considered by staff at the home, and an activities co-ordinator now has responsibility for organising a variety of interesting and stimulating activities, both within and outside the home. Residents are able to choose how they wish to spend their time and some prefer to stay quietly in their room, whilst others like to be more involved. The activities that are available are many and varied, and any suggestions made by residents are implemented whenever possible. There is also extensive photographic evidence recorded in a ‘scrap book’, of many of the enjoyable times that have been spent. A brief written record describes the event, and an evaluation form confirms how much benefit was gained by those who participated. The following list provides examples: • • • • • • • • • • • • • Gardening activities that include planting – cyclamen, primulas and sweet peas, and also creating hanging baskets Knitting circle Craft work - making fridge magnets Talks from various people e.g. the community police officer Musical entertainment Slide shows – travel/steam trains/ wildlife Art therapy Cooking – baking cakes Coffee mornings are held regularly Seasonal activities Reminiscence sessions Bible quiz Hymn singing Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 17 Monthly coach trips are arranged to various places of interest, like the Botanical Gardens in Birmingham, and in addition frequent visits are made to other homes and churches in the Christadelphian group. Some people also enjoy going shopping, or out to a garden centre for morning coffee or afternoon tea. There was said to be something for everyone. One person who I met in the corridor was anxious to show me her room and to discuss what she planned to do that afternoon. There was to be a poetry reading session in the conservatory, and she had been preparing the items that she wished to contribute, from her extensive collection of books. The opportunities that provide stimulation for the people living at the home were very evident, and some people were able to also encourage others by their enthusiasm. There are no specific visiting times and the involvement of family and friends is actively encouraged. Visitors are made very welcome, and include people from the Welfare Committee, who are able to offer support when necessary. The comments from everyone involved with the home were all very positive, both in person and in writing, about the standard of the care, and about the kindness of staff. The arrangements regarding the provision of food reflect the individual likes and dislikes of each service user, and only favourable comments were heard about the standard of the food. Meals were observed to be a pleasant occasion, but the manager expressed the intention to review the organization of the meals, to encourage more interaction between residents and to make mealtimes more of a social occasion. The menus indicated that there is a choice of two main dishes and three pudding options at lunch time, and at tea time there is always a choice sandwiches, salad or a hot snack, followed by cakes, yoghurt or a sweet. Several service users said that they preferred sandwiches in the evening. Fresh fruit is also available at any time. Several comments were made to the inspector about the ‘good food’ that is always served at the home. A visit was made to the kitchen, which was very clean, tidy and well organized. The equipment was said by the cook to all be in good working order, and the records seen were maintained to a satisfactory standard. A new kitchen had been fitted recently, and provides a very spacious and pleasant environment in which to work. The cook confirmed that residents are consulted, and their preferences considered, and that special diets can be provided when required. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. 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. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The culture of the home positively encourages comments, and the procedure for dealing with any concerns ensures that the home is run in the best interests of the service users. The policy and procedures in place at the home relating to abuse, and the training provided for staff, should ensure the protection of the people who live there, and who may be vulnerable. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 19 EVIDENCE: A clear procedure for investigating complaints has been developed, and any issues are dealt with immediately, the inspector was told. Residents are encouraged to speak to the manager about anything that causes them concern. Residents confirmed that they felt confident that any issues raised with the management of the home, would be listened to and addressed in an appropriate way. People felt that their views are welcomed, and they were aware of the procedure to be followed if they needed to voice any concerns. A copy of the complaints procedure is displayed on the notice board. A record is maintained of any concerns brought to the attention of the management, and there were two recorded during the past year, both of which had been dealt with appropriately. They related to the proposed development of part of the garden, which had raised objections from a neighbour, and therefore the scheme has been shelved at present. The manager was advised that further consideration should be given to the matter, and the benefits to residents at the home reviewed, to ensure that the outcome is in their best interests. The home also records any comments or compliments made by residents, their relatives and any visitors to the home, which provides a balanced view of the service. A sample of extracts from the comments log are included below: • • • • • • • • The hard work that goes into organising all the trips is very much appreciated Mom feels really happy and settled here We are grateful that her personal care was looked after with such love and kindness Staff were a real comfort and reassured her during some difficult times She loved the immaculate garden and appreciated being helped to walk around it Thank you for making mom feel safe at night We will remember you all with ever thankful appreciation of the wonderful care that was given You are all considered to be part of our extended family An appropriate policy and procedure is in place regarding the Protection of Vulnerable Adults (PoVA). Training has been provided for staff, to increase their awareness of the many aspects of abuse, and they confirmed their understanding of these matters during discussions at the time of the visit. The records noted that the induction training for all staff also covers abuse and protection issues. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. 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. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a well-maintained house that is clean and comfortable, attractively decorated and furnished, and in an environment that is safe and secure. The location of the house is convenient to local services and facilities, and the layout provides adequate communal space for the needs of the people who live there. The premises are suitable for their purpose, and the ongoing maintenance and upgrading programme, will help to improve and maintain a good quality of life for the residents. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 21 EVIDENCE: Kingsleigh House is a modern, purpose built, two-storey building, situated on the border between Worcestershire and Birmingham. The premises is well maintained, and furnished and decorated to a high standard to provide a comfortable, safe and relaxing place for people to live. The large complex includes Harbinger Court, which consists of several sheltered housing units, and the Kings Norton Christadelphian Meeting room, that can be accessed by residents through a corridor from the home. The building has been sensitively developed and upgraded to provide a pleasant environment for residents. The communal areas of the home are spacious, and include a large lounge, and dining area, and an all weather conservatory, where activities can take place. There is a lovely outlook from the rear of the property across the pleasant gardens that are easily accessible to service users. The bedrooms at Kingsleigh House each have en suite toilet facilities, they exceed the minimum space requirements and are able to accommodate wheel chair users. An extension to the home has provided two large bedrooms on the ground floor, both with en suite shower facilities. They have been registered for shared occupation, if requested, to enable married couples to be accommodated. The home is clean and fresh throughout and staff confirmed that they are familiar with the procedures regarding the control of infection, and that they have also been given training in health and safety matters. A maintenance programme is in place at the home, and over the last twelve months further developments are evident that have improved facilities for residents. The ground floor communal areas have all been decorated, and the curtains replaced. New arm chairs have been provided, for the comfort of residents. The lighting in the sitting room and dining area has been upgraded, and on the first floor the bathroom has been refurbished and a new assisted bath installed. The inspector was told that there are no outstanding requirements following visits to the home in recent months by two Environmental Health Officers, one from Birmingham and one from Worcestershire! A fire audit was undertaken at the home in March 2007, by the West Midlands Fire Service, which confirmed that the fire risk assessment and fire precautions at the home were all satisfactory. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. 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. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is adequately staffed with employees who are experienced and competent to care for older people Residents are supported and protected by the rigorous recruitment and selection procedures that are followed by the management of the home The training programme for staff ensures that each member of staff has a clear understanding of their role, and is able to provide appropriate care for the residents Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 23 EVIDENCE: The staff rotas indicate that staffing is maintained at a level that is appropriate for the needs of the people who live at the home, and this was confirmed in conversation with residents, who are very complimentary in their views about the staff and the care they receive. Comments made to the inspector include: • • • • • • The staff are so kind I know they will always help if I need them I have so many blessings Nothing is too much trouble There is always someone around We are so well looked after There have been some staff changes during the last twelve months, mostly in the senior team, although the group is generally fairly stable. Many of the staff have worked at the home for several years, and form the core of a committed and competent team, that is able to effectively respond to the changing needs of residents. Staff were observed by the inspector to deal very kindly and professionally with residents, and their commitment to maintaining a good standard of care was very evident. The staff with whom the inspector spoke, confirmed that they enjoy their work, and all were very positive about being employed at the home, and also about the training opportunities they are given. Over 90 of the care staff have the NVQ (National Vocational Qualification) Level 2 in Care, and one person is currently taking the award. Three staff have completed Level 3, and there are two NVQ assessors working at the home. Three domestic staff have also completed NVQ Levels 1 & 2 in Domestic Skills. A staff training schedule has been produced to record all the courses that each person has attended, and to identify any training that needs to be done. All staff undertake the induction and foundation training courses to NVQ Level 2. The records indicate that ‘core’ training has been provided for staff in health and safety, basic first aid, fire safety, basic food hygiene, and moving and handling. In addition, some staff have attended care related training sessions on the administration of medication, dementia care, continence, bereavement and abuse awareness. The files of two staff were inspected, and the correct procedures had been followed, in regard to recruitment and selection. Relevant information was recorded and appropriate documentation was in place, and included evidence of Criminal Record Bureau(CRB) checks, the applicants CV, references, proof of identity, and training certificates providing evidence of qualifications. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. 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. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, 36 & 38 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Registered Manager is very experienced, and qualified both in management and care, and residents and staff benefit from the positive approach and the leadership they receive. The quality monitoring system measures the success of the home in achieving the stated aims and objectives for the people who live there. The arrangements for the formal supervision of staff ensure that they fully understand their role, and that career development needs are identified. The health, safety and welfare of residents and staff is promoted and protected in respect of all safe working practices. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 25 EVIDENCE: Kingsleigh House is administered by Christadelphian Care Homes, which is a charitable trust, founded in 1944, and registered with the Charity Commission. Currently there are twelve trustees who meet at least quarterly to discuss management issues. A General Manager and an Assistant General Manager are appointed to implement policy and oversee the management of all the homes operated by the Trust. The registered manager, Mrs Paula Bateman has many years experience in the care of older people, and has a clear understanding of the role and her responsibilities. She has taken the Advanced Management for Care Course and has the Diploma in the Management of Care Services. She has also achieved NVQ Level 4 and the Registered Managers Award. Ms Bateman has good communication skills, and a clear sense of leadership, and the home is being managed in a way that is fully inclusive of service users. For many years she has had support from her deputy, who also has the relevant knowledge and experience to provide a high standard of care, and together they have ensured that the home is run in the best interests of the residents and the staff. The positive interactions between staff and residents are pleasing to observe, and the home very obviously revolves around the people who live there. The commitment of staff to maintaining high standards is commendable. A formal quality assurance system has been developed by the Organisation, and the views of residents and their families are regularly sought, in order to ensure that the home is run in their best interests, and in the way that they wish. In addition residents meetings are held every 2 months, when specific issues are identified, and a monthly visit is also made to the home by a trustee. Informal monitoring is undertaken with the many people who have regular contact with Kingsleigh House, including groups from other homes, relatives, friends and members of the local church. The results are audited externally and the reports are made available on request. Staff do not have responsibility for managing the financial affairs of anyone living at the home. The family or a representative deal with any financial matters, on behalf of residents who are unable, or who do not wish to manage their own affairs. Safe storage of valuables is available, and appropriate records are maintained. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 26 A procedure for the regular, formal supervision and appraisal of staff has been implemented, with appropriate records maintained. Staff confirmed that they felt well supported in their work, and the care manager discussed the process that she follows. A health and safety policy and procedure is in place, and all staff are trained in safe working practices. Contracts are in place for the servicing and maintenance of equipment at the home, and the records are well maintained with all the appropriate certificates available. The Accident Books are completed to a satisfactory standard, and Regulation 37 Notifications, which require reports to be sent to the Commission of the death, injury or serious illness of a service user, or other events in the home, are made to the Commission, when appropriate. Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 3 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 3 Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP33 Good Practice Recommendations The management of the home should continue to critically appraise its practice to ensure the best possible outcomes for residents Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Kingsleigh House DS0000018461.V336916.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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