Inspection on 05/08/08 for Kingsley

This inspection was carried out on 5th August 2008.

CSCI found this care home to be providing an Good service.

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

Kingsley 23/08/06

Kingsley 17/02/06

Kingsley 24/11/05

Kingsley 07/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Kingsley 28 Downs Park Herne Bay Kent CT6 6BZ Lead Inspector Chris Woolf Unannounced Inspection 5 to 11th August 2008 08:55 th Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 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 Kingsley DS0000047949.V369184.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsley Address 28 Downs Park Herne Bay Kent CT6 6BZ 01227 367577 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) rdgrant49@hotmail.com Dyzack Ltd Ms Rhonda Diana Grant Care Home 9 Category(ies) of Learning disability (0) registration, with number of places Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 9. Date of last inspection 23rd August 2006 Brief Description of the Service: Kingsley (the Home) is registered to provide accommodation and personal care for nine younger adults (service users) who have a learning disability. The premises are located in an older detached two-storey property. The ground and first floors are used to provide accommodation for the service users. Each of the service users has their own bedroom, all with a private bath/shower room. The Home is located on a quiet residential street and it is within walking distance of the sea front and Herne Bay shopping centre. The Registered Provider is a private limited company. Mr Z Hasmat Ali one of the Directors of the Company is the Responsible Individual. This means that he is responsible for overseeing the work of the Registered Manager who looks after the Home on a day-to-day basis. The current fees for the service at the time of the visit range from £1200 £1500 per week. Information on the Home’s services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. The e-mail address of the home is rdgrant49@hotmail.com Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Key Lines of Regulatory Assessment (KLORA) have informed the judgements made based on records viewed, observations made and written and verbal responses received. KLORA are guidelines that enable The Commission for Social Care Inspection (CSCI) to make an informed decision about each outcome area. The information for this report has been gained from an Annual Quality Assurance Assessment (AQAA) completed by the service, a site visit to the home, which lasted 4 hours and 40 minutes, and a further visit to the service to look at staffing records, which lasted just over an hour. As some of the service users are autistic and disruption to their normal routine can upset them, we (the Commission) gave the service a day’s notice of the proposed site visit. This enabled the manager to explain to the service users that we were coming and put their minds at ease. During the site visit we talked with the service users, the staff on duty, the trainer, and the Registered Manager. We observed the interactions between service users and staff, activities being undertaken, and lunch being served. We also examined a variety of records including assessments, care plans, risk assessments, daily records, menus, and some safety records. The staff files for this service are kept in services head office in London. It was therefore necessary for arrangements to be made for them to be brought down to Herne Bay. We made a separate visit to examine the recruitment and training files. The people who use this service are generally known as ‘service users’ and this is the term used to describe them throughout this report. What the service does well: Staff in the home are well trained and currently all staff either hold or are working towards NVQ (National Vocational Qualification) at Level 2 or above. Each service user has a care plan which is individualised and person centred. Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 6 Risk assessments are clear and easily understood. Service users are encouraged to lead an active lifestyle. The home has a friendly atmosphere and service users and staff think of it as a large family. The home is run by a competent and caring manager who supports both service users and staff. What has improved since the last inspection? What they could do better: There are no requirements or recommendations made on this report. Kingsley DS0000047949.V369184.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. Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, & 5 Quality in this outcome area is good. People who use the service and their representatives have the information needed to choose a home that will meet their needs This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the home has updated their information about the home, including the contract of terms and conditions, and the service user guide. These documents are now produced in a more user-friendly form including pictorial information. The home has sound procedures for the assessment of prospective service users. The Manager and the Provider visit all prospective service users and carry out an assessment. The home is using the ‘Listen to me’ person centred assessment, which is recognised by the standards as good practice, as well as more formal assessment methods. Once the assessment is completed the manager and provider discuss the person with the staff team and the current Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 10 service users to gain their views. If it is agreed that the prospective service user is suitable for the home, and that the home can meet their needs, a series of trial visits take place. Trial visits include overnight stays. This gives the prospective service user the opportunity to find out first hand what life in the home is like. It also gives the home the opportunity to further assess and be sure that they can meet the needs of the prospective service user; and that they will fit in with the existing service user group. A copy of the joint assessment of the prospective service user is obtained from their Care Manager. There have been no new admissions to this home during the last 3 years. Prospective service users can be confident that their assessed needs will be met by the home. This includes their physical, mental, social, and cultural and diversity needs. The homes AQAA says, ‘We work hard to ensure the promotion of race and gender identity, sexual orientation, age appropriateness, religion and belief within our service. We support service users exploring their cultural and spiritual issues through festivals, culturally appropriate foods and facilitating attendance at worship if this is their wish’. If the home is not confident that they can meet the prospective service users needs, or if they feel that that the person will not fit in with the existing service users, admission will not be arranged. Staff are trained to deal with the needs of the service users including training in learning disability, challenging behaviour, and service users preferred mode of communication. A member of staff said, “You need to know each resident”. Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 Quality in this outcome area is good. Service users are involved in decisions about their lives, and play an active role in planning the care and support they receive This judgement has been made using available evidence including a visit to this service. EVIDENCE: A care plan is developed and agreed with each service user. Care plans are person centred and holistic. They are initially based on the pre-admission assessment. Service users dreams and aspirations are included in the care plan and these are monitored, with achievements being recorded. All care plans are developed and reviewed both on a regular basis, and as any needs change. The service user and their family are involved in the more formal reviews. The homes AQAA says, ‘We are person centred in our approach to Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 12 care planning and risk assessing. We believe that service users should participate as fully as possible in the life of the home’. Behavioural plans are in place where needed. These are clear and easy for staff to follow and include the best way to deflect individual challenging behaviour, using positive support. This consistent approach has lead to less challenging behaviour and increased participation and inclusion in the local community. This home does not operate a key worker system, but with a stable service user and staff team the relationship between service users and all members of staff is very positive. Communication guidelines are included in care plans for any service user who uses alternative means of communication or who has communication difficulties. The homes AQAA says that improvements in the last year include, ‘We have reviewed and developed our care plans and quality assurance guidelines to reflect KLORA (Key Lines of Regulatory Activity) principles’ Service users are encouraged to make decisions about all aspects of their lives in line within their mental and physical capacity. Regular service user meetings are held during which service users have their say about life in the home. The homes AQAA tells us that as a result of listening to what service users have said, ‘ We have increased the amount of information to service users in Makaton, signing, widget and easy read formats’. A member of staff said, “I know how to do basic Makaton signing”. Decisions quoted by staff and service users included, what time to get up and go to bed, what to eat, where to go, what to do, and whether to go out for lunch. On the day of the site visit service users said, “I want to go out for lunch today”, and “I am going out later”. Staff explained that they give appropriate choices to the service users and said, “Usually they have enough choices”, “They have choices in most things”, and “I believe we can achieve things with them if we keep trying”. Several staff have attended Mental Capacity training, this has reinforced the homes policies on choice and capacity. Currently no service users manage their own finances. Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, & 17 Quality in this outcome area is good Service users are able to make choices about their life style, and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes AQAA says, ‘We are person centred and proactive in our approach to lifestyle. Our service users access the community on a daily basis appropriate to their needs. Their choice of activity encourages access to mainstream community experiences as appropriate’. It also tells us that in the past year they have improved by ‘We have used the Listen to Me booklets to Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 14 explore with service users their hopes and dreams. We have revised each service users activity plan to ensure they remain relevant’. Service users are encouraged to continue with education. Where possible service users attend further education courses or training at day centres. Courses are also held in house, particularly for those who are unable or do not wish to attend outside courses. On the day of the site visit a new course was being held in house. Service users were encouraged to set their own objectives and are encouraged to meet these by the trainer. These include such things as Arts/Crafts, Life book, cooking, sport, and even a project on star wars & sci-fi. At the end of the session a service user who had chosen to do arts & crafts said, “I have just made this picture”. Currently there are no service users in paid employment. Staff support the service users to become part of the local community. Each service user has an individual activity planner, which includes weekend activities. The AQAA says, ‘We are person centred and proactive in our approach to lifestyle. Our service users access the community on a daily basis appropriate to their needs. Their choice of activity encourages access to mainstream community experiences as appropriate’. Activities in the community include, drives, swimming, cinema, bowling, day trips, shopping, walks along the seafront, going out for meals or coffee, and activities with the other homes from the group. The home has their own vehicle to take service users out and they also share a second vehicle with the other homes in the group. Service users also make use of public transport. Activities within the home include helping with chores such as service users cleaning their own rooms, hovering and washing. Leisure activities include colouring, use of exercise machine, darts, computer, listening to music, or watching videos and DVD’s. Service users said, “I collect cars”, “I like my video’s”, and “I’ve got a lot of DVD’s”. Staff comments included, “Service users days are full of everything, and weekends even more so”, and “We try to give them as many activities as we can here”. The homes AQAA says improvements in the last year include, ‘‘We have revised each service users activity plan to ensure they remain relevant’. None of the current service users participate in the voting process however politics are discussed in the home to keep service users informed. The home values the racial and cultural diversity of service users, and support individuals in their various religious needs by accompanying them to church or temple when the service user wishes, or by helping them to recite the creed for their religion when this is wanted. The homes AQAA says, ‘We incorporate important (cultural) festivals into the calendar of events’. Service users are encouraged to maintain relationships with their family and friends. Visitors are made welcome but encouraged to telephone in advance to avoid disruption to service users who cannot cope with change to their routine. Staff support service users to visit friends who live locally. Where service Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 15 users families live some distance away staff support them by driving them home for their visits. Daily routines in the home are flexible to meet individual needs. Service users are able to lock their own bedrooms from inside to stop others from intruding on their personal space. Service users are able to choose whether they wish to be alone or in company and whether or not to join in any activity. We observed staff interacting appropriately with service users. The atmosphere was relaxed with service users indicating by their behaviours that they are happy with the staff that care for them and the pace of their life. Meals in the home are flexible. The menu for the day is discussed at breakfast and service users are offered a choice that meets their dietary and cultural needs and respects their preferences. The home keeps a record of meals taken. A staff member explained that if service users choose a lot of unhealthy food he explains this to them so that they understand and that they will normally then amend their choice. When necessary nutritional assessments are undertaken and the dietician is consulted. The kitchen is spacious and was clean on the day of the visit. It is suitable for service users to take part in cooking tasks when they wish. Fresh fruit and vegetables are available for service usrs. Staff comments about the meals included, “The food is fantastic, even for the staff, we have the same, basically its whatever we all want”, “I have done catering in the past, its helped me a lot”, “There’s lots of vegetables and fruit”, and “I feel like they are at home. We provide what they want”. Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 20 Quality in this outcome area is good The health and personal care that service users receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff support service users to maintain as much of their independence as possible when helping with personal care. Individual personal care needs are recorded and these kept under review, this ensures that service users are supported in the way they prefer. Guidance and support is provided as needed for personal hygiene. Each service user has their own personal en-suite bath or shower room, and this helps them maintain their independence and privacy. Staff confirmed that service users privacy and dignity is always respected and Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 17 said, “We always make sure service users have their privacy”, and “Even when service users are challenging we show that we respect them”. Service users healthcare needs are met by the home supported by a multidisciplinary health care team. The homes AQAA says, ‘We are pro active in ensuring our service users health is promoted. They attend well men’s clinics, dentist, optician and chiropody in a planned format’. Care plans indicated that service users have been in contact with health care and other professionals including doctors, nurses, psychiatrist, clinical psychologist, dentist, chiropodist, optician, community Learning Disabilities team, social worker, dietician, speech and language therapist and well men’s clinic. A service user said, “My tooth is loose”. The manager confirmed that this service user has an appointment with the specialised Learning Disability dentist. The home’s AQAA notes an improvement made during the last year as, ‘We have explored in residents meetings what activities and choices would maintain good health’. The manager explained that a Nutritional Profile has been developed and is now being used by all homes in the group. Currently no service users have chosen to look after their own medication. All staff that assist with medication have been trained and, since the last inspection, are also competency assessed. The homes policies and procedures for the receipt, administration, storage, and disposal of medication are robust. Medication is regularly audited. Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, & 23 Quality in this outcome area is good Service users are able to express their concerns and have access to a robust, effective complaints procedure. Service users are protected from abuse and have their rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear and understandable complaints procedure. The procedure is included in the service user guide and is also produced in ‘widget’ format, which consists of symbols. It was discussed with the Manager that it would be helpful to have a copy of the complaints policy on display for visitors to see and she confirmed that she would organise this. Opportunity is given to service users and their representatives to make complaints or raise issues at review meetings. Regular service user meetings are held and these give an additional forum for service users to air any grievances they may have. Neither the home nor the Commission have received any complaint about the service since the last inspection. Service users are protected from abuse. The home has its own safeguarding policy, they also have a copy of the Kent and Medway multi-agency protection policy. Staff are trained in protection of vulnerable adults. Staff Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 19 spoken to confirm they have attended this training, and that they understand the importance of the whistle blowing policy. A staff member said, “The whistleblowing policy also protects me”. Service users personal allowances are held securely in the home and service users are supported to handle their money in a sensible manner. Individual records are kept of expenditure, and receipts are kept. Aggression and self-harm is understood and supported. Guidelines are clear and based on positive approaches, which is good practice. Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, & 30 Quality in this outcome area is good The physical design and layout of the home enables service users to live in a safe, well-maintained and comfortable environment, which encourages independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Kingsley is an older style property, which has been adapted to meet the needs of the service users. Communal rooms and some bedrooms are on the ground floor with the remainder of the bedrooms and a shared bathroom on the first floor. The home is well maintained. Some damage was noticed to a ceiling in one room. The manager explained that there had been some flooding from the room above and that the repair had been arranged. There is a homely Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 21 atmosphere in the home. Furnishings and fittings throughout are comfortable and homely. Each service user has an individual bedroom. All bedrooms are fitted with an en suite shower or bathroom. There is also a communal bathroom. Each bedroom is individualised to meet the needs and choice of the service user. All bedrooms are lockable to enable service users to enjoy their own personal space and privacy when required. Communal space consists of a spacious and comfortable lounge / dining room / kitchen. The dining room is also used for some activities and training. The kitchen is sufficiently spacious to allow service users to help with food preparation when they choose. There is a rear garden with a patio area and steps to a lawned area. Bar-b-ques and parties are held in the garden in the summer months. The home has a policy of no smoking in the home, but when service users wish they can smoke in the rear garden. The home is clean, hygienic and free from offensive odours. There are appropriate systems in place to control the spread of infection. There is a separate laundry, and the washing machine has the specified programming ability to meet disinfection standards. Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, & 35 Quality in this outcome area is excellent Staff in the home are trained, skilled and in sufficient numbers to support the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Currently all of the staff working at the home have either completed or are working towards NVQ (National Vocational Qualification) at Level 2 or above. In addition staff are trained in Learning Disability specific subjects such as Challenging Behaviour, sign language, and the Mental Capacity Act. Staff said, “I read a lot of information about learning disabilities on the internet”, “I have done training about Taurettes syndrome”, “I have learned some sign language”, and “I know some Makaton”. Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 23 The home operates strict recruitment practices. No member of staff starts work at the home until 2 satisfactory references and a satisfactory check of the Protection of Vulnerable Adults Register have been received. All staff are issued with a copy of the General Social Care Council Code of Conduct. Each member of staff is issued with a statement of terms and conditions of employment. The home uses an induction package for all new staff that complies with the standards of LDAQ (Learning Disability Adult Qualifications) and Skills for Care. The induction is generally undertaken over a week or several weekends, before any work is undertaken in the home and is held at the services own training school. When it is not feasible for the training to be done at the training school, the trainer works alongside the new staff member in a totally supernumerary position within the home until the induction is completed. Staff training in the mandatory health and safety related subjects are all up to date. The home has also introduced competency assessments to ensure that staff are up to date with their practices. The homes AQAA tells us that the format and timings of Staff Meetings have improved since the last inspection. General comments from staff included, “Its nice working here, I am very happy”, “Its like being in your own home - it’s a family”, “You need to know each resident”, and “I love my job, I care a lot about the service users”. Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, & 42 Quality in this outcome area is good. The management and administration of the home is based on openness and respect. A qualified and competent manager runs the home, and has developed effective quality assurance systems. The health, safety and welfare of service users and staff is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager of the home holds a Registered Managers Award (RMA) and an NVQ Level 4 in Care, and has been running this home for a Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 25 number of years. The manager undertakes regular training to update her knowledge and has recently done Protection of Vulnerable Adults at management level. A service user said, “Rhonda is nice”. Staff confirmed that the manager is very supportive to them and said, “I have been here with Rhonda for 7 years, she will sit down and listen and try her best to get you to do your best”, “Rhonda is like a mother. Any time you need her she is available for you”, and “Rhonda respects everyone”. The home has developed its own quality assurance processes. Questionnaires are sent to service users, families, visiting professionals and staff and an analysis is produced of the results. The AQAA which we sent to the home was completed and returned in a timely fashion and included all of the information we required. A training course on Quality Assurance has been held for staff. Regular audits include Regulation 26 visits, and audits of health and safety, property/maintenance, and medication. The home holds ‘Investors in People’ accreditation. There is a development plan in place for the home. The homes AQAA tells us one planned improvement is, ‘One service user has expressed a wish to produce a newsletter for the group of homes to increase service user involvement which we are assisting to develop’. The home protects the health, safety and welfare of service users and staff. The AQAA says, ‘We have an annual plan to ensure all health and safety records and other essential recordings are in place’. All staff undertake regular health and safety related training. All accident/incident reports seen were in order. Fire safety records were seen and all fire testing is up to date. Servicing of all equipment is up to date and recorded. Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 27 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. Refer to Standard Good Practice Recommendations Kingsley DS0000047949.V369184.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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