Inspection on 10/04/08 for Kingsley Cottage

This inspection was carried out on 10th April 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kingsley Cottage 14/04/09

Kingsley Cottage 27/09/06

Kingsley Cottage 22/11/05

Kingsley Cottage 02/08/05

Kingsley Cottage 13/09/04

Kingsley Cottage 29/04/04

Kingsley Cottage 18/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Kingsley Cottage 40 Uxbridge Street Hednesford Cannock Staffordshire WS12 1DB Lead Inspector Linda Clowes Key Unannounced Inspection 09:30 10th April 2008 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 Kingsley Cottage DS0000004966.V363326.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. Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsley Cottage Address 40 Uxbridge Street Hednesford Cannock Staffordshire WS12 1DB 01543 422763 F/P 01543 422763 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) Mr Rughbir Singh Rai Mrs Gurbaksh Kaur Rai Mrs Shirley Catchpole Care Home 17 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (17), of places Physical disability over 65 years of age (3) Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2006 Brief Description of the Service: Kingsley Cottage is a long-standing care home situated in the Hednesford area of Cannock. It is registered to provide personal care and accommodation for seventeen older people. The home is conveniently situated within the town being close to public and community services and with access to public transport which passes the door. There is also a railway station in Hednesford. Limited vehicle parking facilities are provided on site. Service users accommodation is on two floors and consists of fifteen bedrooms - two double and thirteen single, two have en-suite facilities and the shared rooms have privacy screening. There are two assisted bathrooms, a shower room/wet room and four separate toilets. There is a shaft lift to provide easy access to both floors. Aids to daily living are provided throughout the home to promote independence and health and safety. Communal areas consist of two lounges and a conservatory/dining room. There was a hairdressing salon situated in the ‘snug’ off the front lounge area. Externally there are attractive gardens with secluded patio corners and mature borders, trees, shrubs and flowerbeds. As there was no copy of the Statement of Purpose, Service User Guide on the premises it was not possible to identify what the current fees are. The reader may wish to contact the service for up to date information as to how much the service charges and what is included. Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. One inspector carried out this unannounced inspection and inspected against the National Minimum Standards for Care Homes for Older People and the Care Homes Regulations 2001. The inspection took place over a period of seven hours and included an examination of records, service user plans, personnel files and associated recruitment procedures, complaints files, health and safety records and a feedback session. Various methods were used to obtain information regarding the service provided. Questionnaires were forwarded to eleven service users and we had eight responses. The manager has completed an Annual Quality Assurance Assessment (AQAA), which comprises a self assessment and statistical information regarding the service. Information provided in the AQAA has been used as part of this inspection report. On the day of this inspection visit Kingsley Cottage was fully occupied and the proprietor confirmed that there was a waiting list of people wishing to reside in the home. Several areas of the home were in need of upgrading. The proprietor confirmed that by December 2008 one bathroom would be fully upgraded (including knocking through to one toilet area) to provide a safer and more pleasant environment. Mr Rai, proprietor, also confirmed that by September 2008 the front driveway to the home would be redesigned and the pathways and parking areas resurfaced to improve access and health and safety. Work was also planned to upgrade fire equipment to meet Fire Safety Regulations by February 2009. The inspection found that good quality personal care services were provided. Service users and relatives all expressed satisfaction with the service provided at Kingsley Cottage and the dedication of the staff. Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home must improve its staff recruitment procedures, to make sure that the service users are being cared for by the right people. All new staff must be Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 7 subject to the appropriate legislative checks before they work with the service users. The Home must continue to make improvements to the environment, particularly where the Health and Safety of the service users is compromised. The home’s Statement of Purpose must be readily available in the home. 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 Cottage DS0000004966.V363326.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 Kingsley Cottage DS0000004966.V363326.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): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information has been developed about the Home but this is not always readily available or accessible to the service users. Before people move into the Home their needs are assessed to ensure that they can be met. EVIDENCE: When the proprietor was asked for a copy of the Statement of Purpose he indicated that this was at home on his computer, in the process of being reviewed. This document was not available throughout the day of the inspection. It was not possible therefore, to confirm that current fees were included in the document and are not, therefore, included in this report. The service users should have access to a current Statement of Purpose. This will allow service users, relatives and social and healthcare professionals the opportunity to know what to expect from the service and what is included in their fees. However, service users who responded to surveys confirmed that they had received sufficient information about the home. Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 10 Whilst the manager and proprietor indicated that written confirmation was sent to prospective service users stating that the home was able to meet the individual’s care needs, there were no copies held on files. As part of this inspection it is recommended that a copy be held on each service users file as part of the contractual arrangements between the home and the service user. Those spoken with confirmed that the manager had visited them to carry out an assessment prior to their admission to Kingsley Cottage. On the day of this inspection the home was fully occupied. The inspector was informed that there was a waiting list of people wishing to live in the home. The home does not provide intermediate care and so Standard 6 was not inspected. Kingsley Cottage DS0000004966.V363326.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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home maintains comprehensive and informative plans of care for each individual to ensure a person centred approach to service delivery. The people who used the service are treated with respect and their rights to privacy upheld. EVIDENCE: The care records of three service users were checked. Two service users were funded by the local authority and one was paying privately. Individual care plans reflected individual choices and goals and were regularly reviewed with input from service users and relatives. Information focused on how individuals will develop skills and recorded their future aspirations. Details of progress and achievements were recorded. Risk assessments were carried out and a copy held on each file. These were reviewed regularly or at point of change. The records informed staff of the aims and objectives for the individual in relation to their health, personal and social care needs. Staff spoken with were aware of the needs of service users and confirmed that they referred to the Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 12 care plan documentation on a daily basis. There were good shift change-over procedures to keep staff informed of any changes that may have occurred. We spoke with the three service users whose care we case tracked, as well as many other residents on the day, regarding the service they received. Each was very satisfied with the support they received in the home and confirmed that staff were attentive and sensitive to their needs. Without exception, service users confirmed that their rights to confidentiality were upheld by staff at all levels. All service users confirmed that they received visits from General Practitioners and Community Nurses and that their health needs were promptly addressed. One service user was bedfast on the day but spoke with the inspector. She was very frail and told the inspector she wished to stay in bed. It was noted that staff monitored her and responded promptly when she called. We monitored medication procedures and found satisfactory records which included a photograph of each individual. The Medication Administration Record (MAR) was appropriately completed. The majority of medicines and creams were appropriately and securely stored. It was noticed, however, that some medicines were stored in a separate storeroom that on the day of the inspection was very warm. It was recommended that a thermometer be located in this area in order to accurately monitor the temperature. Should the area become warmer than recommended for the storage of medicines the home must remove medication to a more suitable environment. Those service users who were part of case tracking confirmed that they were highly satisfied with the care they received in the home. This was the case with many other service users spoken with on the day. Several visitors spoke with the inspector and all expressed satisfaction with the way their relatives were cared for. One relative said that they would have no worries about moving into the home when their time came to be looked after. There were no negative comments received from service users who responded to surveys. There had been two deaths in the home and two in hospital since the last inspection. Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are helped to exercise choice and control over their lives. Family and community links are promoted. Service users are provided with and encouraged to maintain a wholesome, balanced diet. EVIDENCE: The service is committed to enabling residents to develop or maintain skills, including social, emotional, communication and independent living skills. Individuals are supported to identify their goals and work to achieve them. The manager and senior staff have undertaken dementia training in order that they may provide sensitive and appropriate support to service users in the home who have dementia care needs. Those service users who were case tracked confirmed that their preferences and aspirations were promoted by staff. Individual lifestyles were taken into account. Some liked to spend much of the day in the communal lounges, whilst others preferred to spend more time in their individual bedrooms. Each was accommodated by the home and regular checks were made on all service users throughout the day and night. Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 14 Several relatives visited the home on the day of this inspection. All confirmed that managers and staff always made them welcome. Only positive comments were made to the inspector with all stating that they had no concerns whatsoever regarding their relatives’ quality of life in the home. One relative said that she would like to live at Kingsley Cottage if she ever required residential care. Residents were able to take part in activities or not to take part as they so wished. The activities programme last year included visits to external places of interest such as The Monkey World at Trentham, a steam train ride, Calf Heath Marina etc. Mystery Tours were planed for 21st April 2008 and 2nd May 2008. Bingo took place on the day and other board games were played. A list of everyone’s birthdays was seen on the wall and residents confirmed that they would have birthday teas to celebrate each birthday. The home assisted service users to attend places of worship on a regular basis and the service users involved told the inspector they really enjoyed their weekly church visits. There was a varied menu with a number of choices, including a healthy option. The meals are balanced and nutritious and cater for the individual dietary needs of individuals. The cooks and care staff in the home who were involved in food preparation had all attained Food Hygiene Certificates. Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an open culture in the home, which allows the people using the service and others to express their views, although the staff and management need to demonstrate that they would know what to do if an abusive situation occurred. EVIDENCE: The home maintained a Complaints Record although none was recorded. The AQAA document indicated that Kingsley Cottage had received no complaints since the last inspection. The CSCI had received no formal complaints about the home since the last inspection. All people who returned surveys confirmed that they were aware of the home’s complaints procedure. A copy of the Complaints Procedure was displayed in the home. All people who returned surveys confirmed that they were aware of the home’s complaints procedure. There had been no safeguarding issues since the last inspection. It was identified that the home did not have a current copy of the local authority’s Safeguarding Procedures. It was recommended that they contact the local authority without delay to obtain this document in order that they may make appropriately and timely referrals as necessary. Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 16 We did find that two staff had been employed without the results of the appropriate checks, which does not fully safeguard the service users. The AQAA document identified that staff had attended training for the Protection of Vulnerable Adults and two staff spoken with confirmed this. Any new staff to the home would undertake Vulnerable Adults training as part of their induction training. “Whistle Blowing” procedures are also provided for staff during their induction. All service users who were case tracked confirmed they felt safe in the home and would be confident raising any concerns they might have with the manager or care staff and felt confident they would be promptly dealt with. On the day the inspector observed that service users appeared relaxed and confident in their approaches to all staff in the home. Staff and the proprietor were seen responding in a friendly, positive and respectful manner to all service users. Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 17 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): 19,21,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is kept clean and free from malodour. Improvements are needed to ensure that the environment is a pleasant and safer place to live. EVIDENCE: Kingsley Cottage Care Home provides services in a converted large, traditional property. As a consequence, bedrooms and corridors are irregularly shaped and sized with relatively few that are alike. This adds to the character of the premises but does cause some difficulty in accommodating any pieces of furniture brought from home. However, no service users complained about the lack of space commenting about the ‘homely feel’ of the building. The home would benefit from an audit of all communal areas to reduce clutter. Items were seen stored in boxes in various parts of the home. Clearing space in the communal areas and corridors would promote good health and safety Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 18 practices and would enable people with walking aids and wheelchairs to more easily access all parts of the home. Service users had a comfortable and homely environment that was warm and cosy. All areas of the home were clean and smelt fresh. Several environmental requirements have been made under the section for Administration and Management as safe working practices, in the last section of this report. At the last inspection a requirement was made for the refurbishment of the bathroom on the first floor. This matter has not been addressed and has been included in this report. The ground floor shower room was obviously not being used by residents and was used as a storeroom. With some renovation this area could be a useful resource for residents. Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home must improve its recruitment practices to ensure that service users are protected. There are sufficient care staff with the skills required to meet service users needs on duty at all times. EVIDENCE: Kingsley Cottage is registered to provide personal care to seventeen older people. On the day the home was fully occupied. There was a staff team of twenty to provide for service users needs. The Manager provided hands-on care as well as undertaking management of the service. We looked at the personnel files of the two latest recruits. It was disappointing to find that the Criminal Records Bureau Enhanced Disclosures (Police Checks) were not current for employment with Kingsley Cottage. Both CRB’s were for other employers. POVA First checks had not been undertaken prior to deployment in the home. The Proprietor was told that he must not deploy care staff unsupervised in the home without current and appropriate CRB’s. It is acknowledged that both staff members were known to other staff and residents in the home, however, robust recruitment procedures must be carried out for all staff in order to determine their fitness to work in the home with vulnerable people. Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 20 The home had a high proportion of long-standing, experienced care staff within its staff team. From the AQAA document it is identified that 14 of the 17 care staff had attained NVQ level 2 in care. Several staff were studying NVQ level 3. Moving and handling training was up to date. The manager was a trained trainer for moving and handling and her training was up to date. The following training had been provided since the last inspection – Basic Food Hygiene for those staff who prepared food, Basic First Aid, Dementia Awareness, Infection Control, Safe Handling of Medicines for those staff who administered medication. Continual Professional Development plans had been developed for all staff to ensure that they had the skills to meet current service user needs. Staff spoken with on the day confirmed that they were well supported in the home and received training to help them provide a good service. Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users enjoy the management style and approach in the Home; this needs to be supported by safer working practices to further promote their health, safety and welfare. EVIDENCE: The proprietor is present in the home from Monday to Friday and every other Saturday morning. Service users, relatives and staff confirmed that he was popular and approachable and it was apparent he had friendly and appropriate relationships at all levels. The manager had a long history of working in social care. She was appropriately trained and experienced to manage the home. She ensured that the home was run in the best interests of service users. It was apparent that Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 22 her leadership style promoted professional and caring relationships in the home. The manager completed and returned the Annual Quality Assurance Assessment, (AQAA) to us within the required timescale. The AQAA is a selfassessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. The AQAA information was brief and gave us some indication of the current situation within the service. There are areas where more supporting evidence would have been useful to illustrate what the Home could do better to improve their service. The manager was aware of the need to ensure that staff at all levels had access to training relevant to the service user groups accommodated. She and the proprietor were seeking training courses for the present year. The AQAA does not confirm the numbers of staff who have attended training in the past year. Regular staff supervision was carried out both formally and informally. The manager also carried out hands-on care in the home and was able to observe practice of the staff team on a daily basis. However the manager was not able to demonstrate that all staff have been recruited safely; that the appropriate checks were made before they starting working with the service users. This places the service users at risk and they need to be able to trust the Home’s recruitment procedures and that they are being cared for by the right people. The home is not involved in the finances of any of its service users preferring residents and relatives to take responsibility. We discussed some areas of improvement needed to improve the Health and Safety of the service users: 1. In the kitchen area that there was debris and dirt that had collected behind the legs of the base units and an extractor fan, which was unserviceable was collecting dust and grime. 2. The driveway of the home needed repair and improvement to remove trip hazards for the benefit of service users and visitors. The proprietor agreed a timescale for completion of this work. 3. The last inspection report required improvements to the upstairs bathroom, which had not been addressed. Discussions took place with the proprietor regarding the upgrading of this bathroom and he agreed a timescale for completion of this work. 4. All hazardous materials must be appropriately stored to comply with Control of Substances Hazardous to Health regulations. 5. Fire training for night staff must be carried out every three months to comply with fire regulations. Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 23 6. The hole in the carpet on the steps on the first floor landing must be repaired/replaced as this presented a trip hazard for service users and staff. 7. Fire risk assessments must be carried out on all service users in the home to ensure their safe evacuation from the area/home in case of fire. The proprietor had already agreed with the Fire Officer for upgrading to several areas in the home with a timescale of February 2009 for completion of the work. The proprietor and manager actively sought the views of service users in relation to all aspects of the home. This was undertaken on an informal basis rather than formal quality assurance systems. Service users confirmed that their views were listened to regarding activities, meals, and their satisfaction with the care provided. Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 24 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 2 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes, see below 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 OP29 Regulation 19(1)(a) (b) & (c) Requirement It is imperative that full recruitment procedures are carried out when recruiting new staff that includes the taking up of appropriate references and police checks (criminal record bureau enhanced disclosures). This will ensure that service users may have confidence in the Kingsley Cottage’s procedures to ensure that all staff who work in the home are fit to do so. Work must be carried out to the front driveway to provide a safe and suitable access/exit for the home. This will promote the health and safety of service users and visitors to Kingsley Cottage. Work must be carried out to improve the bathroom on the first floor. This will improve health and safety for both service users and care staff. This is an outstanding requirement from the last report. Timescale of 30/10/06 not met. DS0000004966.V363326.R01.S.doc Timescale for action 10/04/08 2 OP38 13(4) (a) & (c), 23(2)(o) 30/09/08 3 OP38 23(2)(b) & (c) 24/12/08 Kingsley Cottage Version 5.2 Page 26 4 OP38 13(4)(a) & (c) 5 OP38 13(4)(c) All hazardous materials must be appropriately stored to comply with COSHH regulations. This will promote the health and safety of service users The carpet on the steps on the first floor landing must be replaced where there is a hole as this presents a trip hazard for service users and staff. 10/04/08 30/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations A copy of the Statement of Purpose for Kingsley Cottage must be readily available in the home. This will allow service users and other stakeholders to identify the aims and objectives of the care home and what facilities are available. It is recommended that a following the pre-admission assessment of service users a copy is retained on the individual’s file of the letter from the home confirming that the service is able to meet the service user’s needs. It is recommended that a thermometer be located in the storage area used to store medication. On the day of this inspection this area was very warm. Should the area become warmer than recommended for the storage of medicines the home must remove medication to a more suitable environment. It is recommended that the home obtains a copy of the Local Authority Safeguarding Procedures (Protection of Vulnerable Adults from Abuse) in order to ensure that appropriate referrals are made to the Safeguarding Team. It is recommended than an inspection of the home be carried out with a view to reducing unnecessary clutter in communal areas. This will promote good health and safety practices, provide additional usable space and visually improve the environment. Fire training of night staff must be carried out every three months to comply with Fire Regulations. This will promote DS0000004966.V363326.R01.S.doc Version 5.2 Page 27 2 OP3 3 OP9 4 OP18 5 OP38 6 OP38 Kingsley Cottage 7 OP38 8 OP38 the health and safety of service users in the event of fire All surfaces in the kitchen must be kept clean and hygienic to reduce the spread of infection. In this instance debris and dust must be removed from behind the legs of the base units and the extractor fan that is unserviceable and collecting dust and grime must be removed. Fire risk assessments must be carried out on all service users in the home. This will ensure that in the event of fire each individual’s needs have been assessed and arrangements are in place for safe evacuation from the area/home Kingsley Cottage DS0000004966.V363326.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Kingsley Cottage DS0000004966.V363326.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!