Inspection on 01/12/06 for Kingsleigh Resource Centre

This inspection was carried out on 1st December 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 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 Resource Centre 09/10/09

Kingsleigh Resource Centre 27/05/09

Kingsleigh Resource Centre 27/02/08

Kingsleigh Resource Centre 18/11/05

Kingsleigh Resource Centre 13/06/05

Kingsleigh Resource Centre 26/08/04

Kingsleigh Resource Centre 01/06/04

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

CARE HOMES FOR OLDER PEOPLE Kingsleigh Resource Centre Kingsleigh Kingfield Road Woking Surrey GU22 9EQ Lead Inspector Helen Dickens Key Unannounced Inspection 1st December 2006 10:15 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 Resource Centre DS0000013888.V322236.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 Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsleigh Resource Centre Address Kingsleigh Kingfield Road Woking Surrey GU22 9EQ 01483 740750 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) www.careuk.com Care UK Community Partnerships Limited Ms Karen Seabrook Care Home 50 Category(ies) of Dementia - over 65 years of age (47), Old age, registration, with number not falling within any other category (1), of places Sensory Impairment over 65 years of age (2) Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 2005 Brief Description of the Service: Kingsleigh Resource Centre is run by Care UK Community Partnerships Ltd. The home caters for the needs of older people providing permanent and respite care including care for people with dementia and a day care service. Residential accommodation consists of five self-contained units and each unit caters for ten service users. All bedrooms are single and each unit has a bathroom and toilets, lounge/dining room, and kitchenette. The home has spacious communal areas and has safe, well-maintained gardens. The home is situated near to local shops and community facilities and is approximately two miles from Woking town centre. There are car parking facilities within the grounds of the home. Charges vary but the maximum charge per person per week is £689. Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over 8 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to June 2007. All the key National Minimum Standards for Older People where assessed. The inspection was carried out by Helen Dickens, Lead Inspector for the service. Karen Seabrook, Registered Manager, represented the establishment. A tour of the premises took place and the inspector interviewed 4 residents individually and spoke with others in small groups (including in the day centre), during the tour of the building and at lunchtime. In addition to the registered manager, three staff were spoken to, and a number of documents and files examined as part of the inspection process. The inspector would like to thank the residents, staff, and the Registered Manager for their time, assistance and hospitality. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service users guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. What the service does well: The home continues to be well run and has a happy atmosphere. Residents are well cared for and involved in a variety of activities, which contribute to their good overall quality of life. Residents commented positively on the home and its staff. During interviews with the inspector resident’s comments such as ‘I love being here’ and ‘First class’, were typical. Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 6 Relatives too commented positively; one resident’s relative said they were ‘..overjoyed that my Mum is here.’ Others commented on the high standard of care, the friendliness of the home, and how nice the home smells. Professionals who are involved with the home also gave some positive feedback including comments on the ‘good liaison’ between the home and other professionals, ‘staff are very skilled’, and ‘some excellent feedback from families.’ All those health and social care professionals who had completed a questionnaire (5 in total) answered ‘Yes’ to the question – ‘Are you satisfied with the overall care provided to service users within the home?’ A local taxi driver also completed a comment card and returned it directly to CSCI. The comment on the card said; ‘I have had to pick up many people from homes and I feel that this is the best in the area.’ What has improved since the last inspection? What they could do better: The home are currently reviewing the care planning, staff supervision and training arrangements and all these ongoing projects will need to be completed in a timely fashion. The manager must also ensure that appropriate risk assessments are in place with regard to liquids and toiletries in individual resident’s rooms; this is to minimise the risk if other residents should venture into someone else’s room by mistake. Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 7 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 Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 8 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 Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about where to live. Residents have a written contract containing the terms and conditions for living at Kingsleigh. No resident moves into Kingsleigh without having his or her needs assessed and assured these will be met. Prospective residents have the opportunity to assess the quality, facilities and suitability of the home. EVIDENCE: Prospective residents at this home have a ‘service user guide’ and ‘statement of purpose’ containing the information set down in this Standard. These documents help older people and their relatives to make an informed choice about where to live. New residents also have a ‘welcome pack’. Residents are given a copy of the above documents to keep in their rooms, and spare sets Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 10 are kept in the reception area. Each resident also has a ‘resident friendly’ copy of the complaints procedure on the back of their bedroom door, together with a small notice about the ethos of the home. All of these documents are also available in larger font. Information about CSCI and the latest inspection report was displayed prominently in the reception area. Of those resident’s files checked, privately funded residents each had a copy of their contract on file, with the exception of one who had a new contract and the home were waiting for the resident’s relative to sign. Resident’s who are funded by social services have a different arrangement as their contracts are between social services, the home, and the resident. Of those resident’s files sampled, all had thorough assessments including social services community care assessments completed prior to being admitted to the home. These documents covered personal and healthcare needs, social interests and information about mobility and continence. Residents at this home are offered specialist services for people with dementia. Staff have dementia care training, up-dated at regular intervals, and facilities and services are geared to providing a homely yet safe environment for those who live here. All exits have alarms and sensors so that no resident can leave the premises without staff knowledge; the main door has a key pad which allows people to leave the building but visitors must ring the bell to enter. Gardens are secure and provide a safe and pleasant environment for residents. Prospective residents have the opportunity to visit and assess the home. Some have already been regular respite clients before they move in permanently, and others have used the day centre facilities before moving in. Standard 6 is not applicable at this home. Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are set out in an individual plan of care and healthcare needs are met. The administration of medication is well organised. Residents were observed to be treated respectfully by staff. EVIDENCE: From the full assessment of needs outlined in the previous section, the home has developed an individual plan of care for each resident. At this home care plans are called Care Programmes. One improvement since the last inspection has been to computerize all these records. Although there is a hard copy on each unit for each resident, staff are now used to working with the computerised versions. A ‘cabinet’ has been installed on each unit containing the computer so that care staff are able to up-date these records, and do their daily records, whilst working on the unit. The manager said that some Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 12 residents had taken an interest in these new arrangements and in what staff were doing. Five Care Programmes were sampled and found to contain basic factual information including next of kin and medical details, a personal property list (from when residents first moved in); and information on communication, eating and drinking, personal care and hygiene, and mobility etc. One of the advantages of the computerised system is that where risk assessments are in place under a given heading (e.g. for mobility), the heading appears in red. Likewise, when a Care Programme review is overdue (these are reviewed monthly as per Standard 7), the record flashes yellow. All those sampled had been reviewed within the last month. The manager is currently reviewing these records as there are further improvements which could be made to the system. One issue is with regard to the headings which make up each Care Programme – some important ones (e.g. hygiene) were missing for individual residents, but staff had put the relevant information under a different heading. Staff need more guidance on what aspects of care should fall into each category. There also needs to be a standard set of headings to ensure that all aspects of health and social care are initially considered for each resident, even if no specific needs are subsequently identified. The manager said these refinements would be completed within one month. On the day of the inspection Care UK head office was carrying out work on the computerised system and resident’s risk assessments temporarily disappeared. The manager said the home always keeps a hard copy of any risk assessments for residents on each unit, and this was found to be correct when one was requested. Another improvement over the last year has been the introduction of ‘activity based care’ to the home. Care staff working through this training have become ‘life skills support workers’ with a corresponding job description. A toolkit (which includes pictures of Kingsleigh residents) has gone out to Care UK homes across the country to assist staff in the roll-out of this programme. A trainer is working in the home during its introductory phase. One member of staff has been designated the ‘active living co-ordinator’. The aim is to enable residents to maintain as much autonomy as possible with regard to their care through recognising the skills they already have. Examples of this being put into practice are highlighted elsewhere in this report. Relatives were asked to comment on the home, including the care provided to residents, prior to this inspection and of those ‘comment cards’ returned, all made positive comments including ‘I am very happy with the standard of care’ and ‘I am well impressed with Kingsleigh’. Care Programmes showed resident’s health needs had been identified, particularly those relating to dementia. The incidence of pressure sores is recorded on Care Programmes and specialist input is sought on all health Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 13 matters and recorded, for example from community nurses and the chiropodist. Residents spoken to said they were well looked after and ‘comment cards’ sent out to health and social care professionals who deal with this home were returned with some very positive comments. One GP said that staff behaved in a professional manner and ‘communicate well and appropriately with myself and our practice.’ No residents are responsible for their own medication at this home as all need to be supported by care staff in this regard. One medication administration session was observed and staff were found to be knowledgeable on resident’s needs, to keep the medicines securely and to properly record what had been given. A medication policy is in place as is a system for monitoring unexplained gaps in recording. Three charts were sampled and only one unexplained gap was spotted. The member of staff responsible was quickly identified and the oversight was rectified. Staff were observed to be respectful to residents at all times and personal care was carried out in private. Those residents interviewed made positive comments about the staff and all agreed that the staff treated them well. Relatives made positive comments on how staff behaved towards residents and one wrote ‘The staff are conscientious and concerned for the welfare of those in their care at all times.’ Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s preferences are taken into account and they are supported to exercise some choice and control over their lives. Family and community contact is encouraged, and mealtimes offer a balanced diet in pleasant surroundings. EVIDENCE: Routines of daily living are constantly under review as the home has started to introduce ‘activity based care’ as mentioned earlier in the report. This gives residents a greater involvement in their care and more opportunities to be involved. One example the manager gave was introducing small tea trays with teapots etc so that residents who wished to, could be supported to help themselves to tea. Likewise at breakfast, small pots of marmalade and tiny Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 15 dishes of butter allow residents who are able, to put their own butter and marmalade on their toast rather than having this done by staff. Resident’s interests are recorded on their Care Programmes and the inspection included a visit to the day centre at Kingsleigh. Six older people had come for the day but in addition the activities co-ordinator said 10-15 Kingsleigh residents joined the activities on a daily basis. That morning the group had been concentrating on Christmas activities and there were knitted crackers and Christmas collages in progress, and advent calendars made by residents (with a sweet for each day of advent) hanging on the wall. In the afternoon there was going to be a bingo session. A weekly programme, in words and pictures is set out for residents to keep up with forthcoming events. The activities organiser was very enthusiastic and artistic and residents were benefiting from her hard work. One resident whose first language was not English was given the opportunity to converse with others who spoke their native tongue. This resident’s care manager also spoke briefly to the inspector as she had come to the home to check on arrangements which had been made following a review several days earlier. The care manager was very pleased with the progress which had been made. There seemed to be a good working relationship between the home and the local authority which was to the benefit of this resident. The manager said family and friends are made welcome at Kingsleigh and this was confirmed by those residents spoken with during the inspection. The visiting times are on the door but in fact they can visit more or less anytime by arrangement with staff. The staff were knowledgeable about individual resident’s visitors and the manager said that they had some good relationships with relatives. Comment cards received from relatives included positive comments and a care manager said there had been ‘Some excellent feedback from families during reviews.’ Involvement with the local community s also encouraged for example the local schoolchildren were due to entertain residents later in the week with Christmas carols and then stay for mince pies. Residents do have some opportunities to exercise choice and control and their opinions are sought in a number of ways including through key workers, directly to the manager, and during resident’s meetings. Notes of the resident’s meetings were sampled and these notes go firstly to the manager to instigate any actions necessary, and then they are filed for future reference. Notes showed that resident’s opinions had been sought on a variety of topics, and especially about the food and facilities of the home. Some residents also have an independent advocate who assists them when necessary. All residents are entitled to bring personal possessions with them and those residents who showed the inspector their bedrooms had numerous personal items ranging from small ornaments and photographs, to pieces of furniture and in one case a large flat screen television. Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 16 Residents receive a balanced diet and arrangements are in place for those who need special diets. For example the chef outlined the meals for those residents who needed ‘soft’ diets. The manager said the chef arranges the menu according to the season and input into this is gained at resident’s meetings the chef also goes around the individual units to ask resident’s opinions. On the day of the inspection (Friday) residents were having fried fish and chips which received positive comments from those spoken with. Some residents were having poached rather than fried fish, and the alternative was a chicken pasty – this contained a creamy sauce and puff pastry which was easy to eat for those residents who chose this option. The pudding was homemade rhubarb crumble and custard. Residents were enjoying their lunch and the dining areas were observed to be pleasantly arranged with tablecloths, fresh flowers, and soft drinks available on each table. Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 17 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints made to this home are listened to and acted upon, and residents are protected from abuse. EVIDENCE: This home has a complaints procedure which is displayed in every resident’s room and in the communal area near reception; a large font version is available in the corridor. A record of complaints is kept and two have been received in the last 12 months. These were discussed with the manager and some of the issues highlighted were followed up during the inspection and found to be satisfactory. Comment cards returned from residents indicated they would know who to complain to if they had a problem. Staff at this home have all had protection of vulnerable adults training and are therefore aware of their responsibilities with regard to protecting vulnerable adults. The new nationwide arrangements for induction of care staff (Common Induction Standards) are in place in this home and cover protecting vulnerable adults, for all new recruits. There is a protection of vulnerable adults policy in place. One issue raised earlier in the year has been satisfactorily dealt with. Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a very homely, safe and well maintained environment which is clean, pleasant and hygienic. EVIDENCE: The location and layout of the home is suitable for it’s stated purpose – the home is purpose built and is divided into five smaller homely units. The communal areas are very nicely decorated and a lot of effort has gone in to providing pleasant surroundings. For example chair covers, cushions, table clothes and curtains are all co-ordinated. A selection of very decorative homemade quilts are hung throughout the home, these are also in a variety of colours and patterns which provide an overall well cared for and warm feel to this home. There are arts and crafts made by staff and residents throughout the home, but especially in the day centre area. The indoor and outdoor facilities and security have been devised for the specialist needs of these Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 19 residents. All outer doors are secure and visitors must ring to enter. Doors which lead out onto the secure gardens have sensors so that staff know if a resident leave the building to go into the garden. The home had no Requirements following the last inspection and the home received a good environmental health department report on the kitchen area at Kingsleigh. The manager keeps a maintenance log to ensure that items identified for repair or renewal are dealt with in a timely fashion. Some minor issues highlighted during the inspection were entered into the log. This home is clean and hygienic and there were no offensive odours in any part of the building. The communal areas and main hallways had a warm vanilla fragrance and all the toilets inspected were fresh smelling and clean and tidy. All had individually dispensed hand soap and paper towels. There is a dedicated laundry facility and a member of staff was employed to carry out this function. There is a separate sluicing facility which was found to be clean and tidy. One minor issue was immediately dealt with by the manager who arranged for a member of staff to re-sterilise one of the commode pans. The manager said a new bed pan washer is being purchased to replace the existing machine which is now quite old. Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by the numbers and skill mix of staff. However, more work needs to be done on training and recruitment to meet these Standards in full. EVIDENCE: On the day of the inspection there were sufficient staff on duty to meet resident’s needs and those residents spoken to were complimentary about the staff and the help they received. There is a staff rota in place which shows extra staff at busy periods during the day. There are sufficient domestic staff to keep the home clean and hygienic and to ensure that Standards relating to food are fully met. A number of staff (12) have completed the NVQ2 (or above) qualification and a number of others have enrolled on NVQ courses and will finish in 2007. One senior member of staff has been offering NVQ support group sessions to those staff undertaking these qualifications every fortnight. However, the home do not currently have 50 of their staff trained to NVQ2 or above as set down in this Standard (28.1) and more work will needs to be done in this regard. Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 21 The registered manager operates the recruitment procedure at this home and staff recruitment files examined had a completed application form, two written references, and CRB and pova checks. However, since July 2004 the Care Homes Regulations 2001(as amended) have required a ‘full employment history’ for all new staff who began employment after that date. The Care UK application form still requests only a 7 year history and the registered manager has issued a form to all staff requesting them to supply the information as set down in this Regulation (and Schedule 2). This exercise needs to be completed in a timely fashion in order to meet this Standard in full. A senior member of staff has recently taken over responsibility for staff training and is currently up-dating training records for all staff and devising a staff training and development programme for the home. The October 2006 Management Report shows that not all staff are up to date with their refresher training including first aid and health and safety. The staff member responsible for co-ordinating and documenting the training has completed a course in training people in moving and handling and so far thirty staff have received refresher training. The home has introduced the Common Induction Standards and two new staff were working through these on a computer-based programme which has been introduced by Care UK. The work on up-dating training records, and finalising a training and development programme needs to be completed in order to meet this Standard in full. Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 22 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): 31,32,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a well managed home which is run in their interests. Their financial interests are safeguarded by the home’s procedures. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The manager has been at this home for 5 years and previously was a team leader and deputy at another establishment before returning to Kingsleigh. Her experience in working with older people with dementia goes back at least 15 years. Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 23 She has an NVQ 4 in management and the Registered Managers Award. She also completed the Certificate in Management studies 4 years ago. This year training included financial training regarding budgets and was an internal course with Care UK. Her recent training has included health and safety and dementia training and she was due to attend a recruitment training course the following week. There are clear lines of accountability in the home and with external management from Care UK. Residents benefit from the ethos, leadership and management approach at this home. There is a warm and friendly atmosphere and residents spoken to all reported being happy and well looked after. The manager was observed to communicate a clear sense of direction and leadership, and staff were observed to respond well and to be working as a team. The General Social Care Council Code of Practice was displayed in the training room and staff signed to say they had read and received a copy. Management planning at this home involves staff and residents and the ‘activity based care’ approach being rolled out at Kingsleigh demonstrated this in practice. Kingsleigh has internal quality assurance systems in place and a business plan with goals and actions for the coming year. The manager was asked to include more information with regard to aims and outcomes for service users as outlined in Standard 33.2. The organisation has a clinical governance director who audits the home using similar categories to the CSCI Standards for example record keeping, personal care, and medicines. Staff assist with completing audits and there are benchmarks in place for areas such as food and nutrition, privacy and dignity and communication. There is a service user involvement file which records meetings with residents and relatives, and there is a suggestion box in the front reception and a customer satisfaction form can be used. The CSCI comment cards sent out prior to this inspection were also made available to residents, relatives and other stakeholders. The manager said general meetings with relatives are not that popular but she feels she has a good relationship with all the relatives individually. She is currently arranging a talk for relatives on ‘activity based care’, and is planning on publishing the collated information from satisfaction surveys in a newsletter. Regarding resident’s finances, all new residents have a letter stating there will be expenses such as hairdressing and chiropody etc; this is available in large font in the welcome pack, and financial procedures are also set out in this guide. A few residents have SCC acting for them otherwise relatives (or solicitors) pay money into a personal account for each resident – there are computer and hard copies of these financial records. Two service users accounts were checked and the written records and cash tins found to correspond. Residents can lock valuables either in the office safe, or in the lockable box in their rooms in their wardrobe. Also each resident has a locked drawer for toiletries. Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 24 Formal supervision arrangements need to be reviewed as, whilst there is good supervision for new members of staff through induction arrangements, the supervision timetable for other staff has slipped and not all staff are receiving the six supervision sessions per year as set down in this Standard. The manager said other senior staff are receiving training in giving supervision as this will ensure the required formal supervisions can be provided to all staff. Health and safety arrangements at this home were found to be good. The Environmental Health Officers report earlier in the year recorded that no problems were found. During the tour of the building various bath aids were checked for servicing and all had been checked within the last 6 months. Hot water in basins available to residents was checked randomly throughout the visit and all found to be within acceptable limits; radiators had radiator covers to protect residents from hot surfaces; and all communal hand washing facilities had individually dispensed soap and paper towels. The hazardous substances cupboard was found to be secured with a large bolt, out of reach of residents, whilst the handyman was replacing the lock – the manager said this work was expected to be completed that day. The insurance certificate was displayed in the main reception area. The home has some good systems in place for monitoring health and safety issues for example the monthly management review contains an accident analysis and the overall rate and type of accident is monitored by a designated person within Care UK. One staff member is now trained to carry out manual handling training to staff and this will ensure all staff are correctly trained and attend refresher courses in a timely fashion. The manager was asked to ensure that all staff had up-todate health and safety training as currently there is no central list – this was discussed earlier under the standards on training. The manager was also asked to ensure that risk assessments are in place where toiletries are left out in resident’s bedrooms, if they could pose a hazard to other residents who may venture in there by mistake. Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 25 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 2 X 2 Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement The registered person must ensure that each resident’s Care Programme contains all the appropriate basic headings to ensure all relevant needs are considered. They must also ensure that staff are given further guidance on what information should be included as discussed during the inspection and under Standard 7 in this report. The registered person must ensure that a training and development programme is in place (Standard 30) to make sure that care staff are suitably qualified and are given training appropriate to the work they are to perform including 50 of staff trained to NVQ2 or above as set down in the NMS (28.1) and as discussed in the report. The registered person must ensure that all the information set out in Regulation 19 and Schedule 2 of the Care Homes Regulations 2001 (as amended) is gained for all new staff including a full employment DS0000013888.V322236.R01.S.doc Timescale for action 01/02/07 2. OP28 18(1)(a) ( c)(i) 01/01/07 3. OP29 19 Schedule 2 07/12/06 Kingsleigh Resource Centre Version 5.2 Page 27 4. OP36 18(2)(a) 5. OP38 13(4)(a) (b)(c) history for those who have started at the home since July 2004. The registered person must ensure that staff are supervised including formal staff supervision at least 6 times per year as set out in this Standard. The registered person must ensure risk assessments are in place regarding liquids and toiletries in resident’s bedrooms as discussed during the inspection and outlined in the final section of this report. 01/01/07 03/12/06 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 Kingsleigh Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Resource Centre DS0000013888.V322236.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!