CARE HOMES FOR OLDER PEOPLE
Kingsleigh Resource Centre Kingsleigh Kingfield Road Woking Surrey GU22 9EQ Lead Inspector
Lisa Johnson Announced 13 June 2005 10:00 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 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 H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care UK Community Partnerships Ltd, Connaught House, 850 The Crescent, Colchester Business Park, Colchester, Essex, CO4 4YQ Ms Karen Seabrook Care Home (CRH) 50 Category(ies) of Old age, not falling within any other category registration, with number (OP) 1 of places Dementia - over 65 years of age (DE(E)) 47 Sensory Impairment over 65 years of age (SI(E)) 2 Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26 August 2004 Brief Description of the Service: Kingsleigh resource centre caters for the needs of older people providing permanent and respite care including care for people with dementia and a day care service. Residential accomodation 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 a safe, well maintained garden. the home is situated near to local shops and community facilities and is approximately two miles from woking town centre., Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the home first inspection carried out for 2005/2006.and this was an announced inspection, which meant that the staff and residents were aware that the Commission for Social Care Inspection were visiting. The inspector arrived at 11am leaving at 5.40 pm. The first part of the inspection consisted of the inspector touring the home and being introduced to some of the residents and staff, this followed by the inspector having a discussion with the manager looking at the requirements made from the last inspection. Records were sampled.and the inspector attended a staff shift change over meeting. The activities centre was visited and the catering arrangements were checked including looking at the menus and food hygiene practices. The inspector visited the residential units and spoke to some of the residents and staff in each unit and also had the opportunity to speak to three relatives who were visiting. One relative stated, “There is wonderful sense of freedom in the home, it is homely. The staff are friendly, they make you feel welcome and the level of support is very good” The inspector would like to thank the residents and staff for their time and hospitality in carrying out this inspection. What the service does well:
The home benefits from a staff team that understand the needs of the residents well and have received dementia care training. The home has a comprehensive statement of purpose and a staff handbook is made available. A service use guide has been implemented and documents are available in large print to assist residents. Comprehensive policies and procedures are in place and the standard of record keeping is good. The home is spacious and the gardens are well maintained. The day activities centre has a good range of recreational and social activities. Comprehensive care plans are in place, which take account of risks to service users. The staff team communicate well and the homes chef takes an active part in monitoring the diets of the residents and liaises with both residents and relatives.
Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 6 Residents meetings are held in the home and a quality assurance system is in place where customer questionnaires have been implemented. Positive interaction was observed between staff and residents, one relative stated. “There is a wonderful sense of freedom in the home, the staff are friendly, they make you feel welcome and the level of support is very good”. What has improved since the last inspection? What they could do better:
Some staff still need to receive up-to-date supervision in order to ensure they are doing their jobs competently and this continues to be a requirement. All dates of any staff training undertaken must be recorded. The complaints procedure needs to be amended in order to inform residents and relatives/others that the Commission for Social Care Inspection can be contacted at any stage of a complaint. All care plans require a photograph of each individual on them and all of the individual care plans and profiles should state the leisure and recreational activity preferences of each individual in the home. The home undertakes regular residents meetings, however a recommendation was made that an action plan is implemented.
Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 7 A pervading odour was found in C unit, therefore the carpet requires deep cleaning enhancing the environment for residents. A recommendation has been made to replace the dining room chairs that are becoming worn. 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. Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 & 5 The homes statement of purpose provides adequate information to enable prospective residents to decide whether they wish to live there. Contracts are in place and assessments are completed prior to residents being admitted and trial visits and stays are offered. EVIDENCE: A comprehensive statement of purpose and service user guide is available which consists of the aims and objectives of the home and the services that the home is able to offer. A copy of the homes complaints procedure is made available. All residents receive an individual contract in the form of a statement of terms and conditions. Assessments are completed before any person is admitted to the home. All prospective residents and relatives are invited to visit the home. Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8. 9, 10 & 11 The health and personal care needs of residents are being met and risk assessments have been implemented Residents are treated with dignity and respect. Residents are protected by the homes policies and procedures for dealing with medicines. A policy has been implemented in respect ageing, illness and death of a resident and is handled with respect and as the individual would wish. EVIDENCE: Care plans are implemented and goals are based on the assessments of individual needs. Evidence was available that reviews take place every three months. Water low-pressure area, continence and nutritional assessments are in place where required and daily records reflect the goal plans for each resident. There are arrangements in place to access support services. The G.P visits weekly or as required and the district nurse visits weekly. Referrals to an audiologist, occupational health therapist, speech therapist and physiotherapists and community mental health nurse are made through the G.P. A staff handover was observed and staff were found to have a good knowledge of the health needs of the residents in the home. Risk assessments were in place including plans for residents who may be at risk of falls.
Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 11 Medication procedures are of a good standard. Medication records were completed correctly and a clear audit trail is in place. A list was available of all staff that are able to administer medication and a record up to date staff training is maintained. Controlled medication maintained in the home is stored appropriately and the register maintained. A sample of the controlled medication stock was sampled and found to be correct. Views received from residents in the home indicate that they feel well cared for, and are treated with respect and dignity. A policy is available in the home for responding to the death of a resident. Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 The home provides a range of activities and the dietary needs of residents are well catered for with a balanced and varied choice that meets the resident’s preferences and choices were promoted in the home. Residents are able to maintain contact with their family and friends and the local community. EVIDENCE: There is an activities day centre in the home which residents were observed to enjoy. Residents are given the choice whether they wish to attend this facility or not. The environment was found to have a relaxed atmosphere. At the time of the inspection residents were undertaking a range of craftwork and handicrafts. The home holds a Christmas and summer fete where residents get involved making items and photographs, which were on display. The centre has a garden area and a herb garden. A television and video is provided and the service has obtained some talking tapes. Visits take place from the local school and there are opportunities to go shopping, attending church, visiting shows and going to the pub. Some annual outings take place. A mobile library visits the home and at the time of the inspection some of the residents were having their hair styled from the visiting hairdresser. Games of bingo are held and residents have the opportunity to vote in elections. Relatives and friends are able to visit at anytime. Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 13 However the home must update its profiles documenting the resident’s preferences and recording when activities are undertaken and a requirement has been made. The home provides a varied menu and meals were of a good standard and were nutritious. The homes chef discusses food preferences with both residents and relatives. A weekly monitoring record is maintained for all residents and these were sampled. The dietary needs of the residents are responded to, for example service users who require high or low calorie diets. Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 The home has an adequate complaints procedure with evidence that residents and relatives feel that their views are listened to. The staff team have knowledge and an understanding of the protection of vulnerable adult process. EVIDENCE: A complaints policy is in place and it is made available to residents and relatives. A register is maintained in the home. There have been five complaints since the last inspection. Evidence was seen that complaints are responded to efficiently and in the agreed time scales. A requirement has been made that the complaints policy is amended to state that the Commission for Social Care inspection can be contacted at any step in the process. The local authority multi-agency procedure for the protection of vulnerable adults was available in the home and evidence was available that staff attend adult protection training. Views were received from three residents in the home who state that they feel safe and know who they could approach if they were unhappy with their care. Relatives spoken to state that the manager is approachable and another relative stated, “The level of support from the staff is good, my relative is looked after well”. Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23,24,25 &26 Progress has been made in improving the environment creating a safe, comfortable setting for the residents. Adequate environmental policies and procedures are in place. A carpet in one dining room requires cleaning. EVIDENCE: The home has made progress in redecorating and replacing furnishings in some areas of the home. The home was in a good state of repair. The home consists of five units and each unit has its own kitchen, dining/sitting room and there is ample communal space. The home has well maintained gardens. Bedrooms are bright and spacious and were personalised with belongings. Accessible toilets and bathrooms were available. The home was found to be clean and hygienic, but a pervading odour was found in “C” unit and a requirement was made that the carpet is deep cleaned. A recommendation has been made that dining room chairs are replaced in one dining room as they were becoming worn. Policies and procedures are in place and evidence was available that Fridge and freezer temperatures are checked daily, water temperatures are monitored and
Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 16 hazardous substances are locked away. Fire drills take place regularly and equipment and fire alarm checks are updated and recorded. Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 28 & 29 & 30 Progress has been made in increasing the staffing levels, which are now adequate to meet the needs of the residents. Adequate recruitment practices were in place to ensure the safety and protection of residents. Staff training and development is encouraged but supervision sessions need to be updated. EVIDENCE: The home has increased it staffing levels, which now enables ten staff to be on duty in the morning. There has been no change to the levels for the afternoon shift, which is seven staff on shift plus one team leader. The home has appointed a new Team Leader and care staff and three staff files were sampled. Staff files contain evidence that police checks are carried out, photographs, references and identification are in place. Training and development takes place, including mandatory training and support with National Vocational Qualifications. Other training, which has taken place, includes care planning, pressure area care and supervision. All new staff are provided with comprehensive induction training, which was confirmed by new staff spoken to. Individual files are maintained for all training and development and these were sampled, but some files need updating so that dates of any training received must be recorded. The home has made progress implementing supervision but a requirement has been made that all staff need to have more regular supervision. Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36, 37 &38 The home is managed well and an open management approach is in place. There is an effective quality assurance system in place to ensure that the home is run in the best interest of the residents. Comprehensive policies and procedures are in place to ensure the welfare of residents and staff. The Health and safety of residents was promoted in the home. EVIDENCE: The management style in the home was found to be open. Staff and residents and relatives confirmed that the manager is approachable and supportive. Good communication systems were observed and confirmed by the staff. A comprehensive range of policies and procedures were available and communicated to the staff. Staff and resident meetings are held regularly and. detailed health and safety risk assessments have been undertaken. Monthly quality visits and reports from the responsible individual are being regularly completed and quality assurance systems are in place. It was pleasing to see
Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 19 that the manager is implementing a self-audit tool based on the National Minimum Standards for older people. Finance systems were sampled in relation to resident’s finances and these were found to be satisfactory. All staff supervision is to be updated and training records for staff are to be recorded. With the appointment of a new team leader the manager felt that progress could be made. Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 3 3 3 x 3 2 3 3 Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 21 yes 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 7 Regulation 15 Requirement Individual profiles must be completed specifically in relation to the hobbies and interests of the residents A photograph of each resident must be made available on all personal files The flooring in the dining room in Cunit must be deep cleaned or replaced The homes complaints procedure must state that CSCI can be contacted at any stage should a complainent wish to do so. All staff must recieve regular supevision ( Timescale 25/10/04 not met) The training dates for any training undertaken by staff must be recorded and updated Timescale for action 3 months 9th September 2005 1 month 9th July 2005 1 month 9th July 2005 1 month(9th July 2005 3 months 9th september 2005 2 months 9th August 2005 2. 3. 4. 7 26 16 17(a) schedule 3 23 (2) (d) 22 (7)(a,b) schedule 1 18 5. 36 6. 30 17 (3) schedule 1 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
H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 22 Kingsleigh Resource Centre 1. 2. 19 16 The home should consider replacing the dining room chairs in C unit. The home should consider imlementing an action plan to record any follow up actions taken after residents meetings Kingsleigh Resource Centre H58 S13888 Kingsleigh V223019 130605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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