Inspection on 17/01/07 for Kingsley House

This inspection was carried out on 17th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kingsley House 19/09/07

Kingsley House 13/02/06

Kingsley House 10/11/05

Kingsley House 29/09/04

Kingsley House 05/05/04

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Kingsley House 16 Dudley Road New Brighton Wallasey Wirral CH45 9JP Lead Inspector Debbie Corcoran Unannounced Inspection 10:30 17 January 2007 th Kingsley House DS0000018906.V307481.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 House DS0000018906.V307481.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 and 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 House DS0000018906.V307481.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsley House Address 16 Dudley Road New Brighton Wallasey Wirral CH45 9JP 0151 630 3714 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 David Christopher Russell Mrs Ellen Ann Crofts Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Only twelve (12) adults (aged 18 - 64 years) may be accommodated. Only four (4) named older persons (aged 65 years and over) may be accommodated. 13th February 2006 Date of last inspection Brief Description of the Service: Kingsley House is a three storey, Victorian house, offering care and accommodation to 14 adults and 2 older people with mental health needs. Situated in the centre of New Brighton, close to a variety of shops and community facilities. The home is within reach of the main waterfront, bus and rail services. Accommodation is provided in eight single and four shared bedrooms, one double room upon the ground floor has en-suite facilities. There is an additional bedroom on the ground floor, which is used by staff for sleep in duties. Two communal lounges are available on the ground floor. The residents have designated the smaller lounge as a no smoking area. The dining room is situated within the conservatory, which overlooks the rear garden area. The kitchen is situated in the middle of the house in between the main lounge and the conservatory. Access between the ground, first and second floor is via the main staircase. A passenger lift is not available in this home. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit to the home was not announced beforehand. During the visit the majority of the residents were met and spoken with and a number were spoken with on a one to one basis. The home manager, home owner and member of the staff team were also spoken with. A sample of resident’s records were looked at. Other records looked at include staff files, staff training records and health and safety records. A tour of the home was carried out which included all areas. The manager returned a questionnaire on the service to the Commission and a number of residents returned questionnaires. Some of the information contained in these has been used to inform the findings of this inspection. What the service does well: The residents were very positive about all aspects of the home. Resident’s comments included “It’s lovely here” and “this is a good place, it’s the best”. The home feels welcoming, homely and relaxed. Residents are contributing to decision making in the home and are making choices with regard to their daily routines. Residents meetings take place on a regular basis and residents are also given further opportunities to comment on the home through questionnaires. Staff are being provided with some good training opportunities and further training is planned for the future. A good percentage (75 ) of staff are qualified to a National Vocational Qualification (N.V.Q) level 2 in care. Staff appear to have a good understanding of the needs of the residents and there were some good examples noted of how staff support the residents with developing their personal and independent living skills and using the local community. Staff were observed to be pleasant and respectful to residents and welcoming to visitors. Residents gave very good feedback on the staffing and management of the home and made comments such as “The manager Ann is lovely and very good” and “we go to the pub on Wednesday afternoons, Dave takes us, he’s lovely”. Health and safety procedures are in place so as to ensure the home environment is safe to residents, staff and visitors. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 (adults 18-65) 3, 6 (older people) These standards could not be practically assessed. EVIDENCE: There have been no new service users to the home for almost two years and therefore the current assessment and referrals processes used at the home could not be practically assessed. The manager reported that she does attain information on the needs of a prospective resident from the relevant Social Services department. The manager reported that she carries out a risk assessment prior to admitting a resident to the home and will only admit a person whose needs can be appropriately met. The home provides long term care only and does not provide intermediate care. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 (adults 18-65) 17,14,33 (older people) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents care plans do not provide sufficiently detailed information as to how to support the residents in all aspects of their health, personal and social care needs. Service users are encouraged and supported to make their own decisions and to participate in the decision making in the home. When a service user is involved in an activity which involves taking risks then the risk is assessed and plans are put in place to manage the risk. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 10 EVIDENCE: A sample of resident’s records were examined in order to assess the care planning in place for residents. For a number of residents there was no care plan available on their records. The responsible person has reported that these were located following the inspection visit and he has provided confirmation of this. For other residents there was a write up referred to as a care plan but these contained minimal information as to the person’s needs and how they should be met. Because the information in residents care plans and records was minimal it proved difficult to evidence that residents care and health needs are being met. The manager must ensure that there is a clear and auditable link between identifying a residents needs and ensuring an appropriate care plan is in place which meets the identified needs. Care plans must cover all aspects of a person’s support including their psychological well being and needs specific to their mental health. The responsible person has reported that they intend to introduce a new system for care planning which should ensure all the required information is included. Residents, and as appropriate their representatives, should be included in the development of their care plan. Many of the staff have worked at the home for a significant period of time and so, although the care planning is poor staff do appear to know the needs of the residents well and they have had the opportunity to build good relationships with the residents and this is very positive. Residents were very positive about all aspects of their support and appeared confident that staff were meeting their needs and providing good care and support. Residents who were spoken with said that they are making their own decisions as to their daily support and their routines within the home. Residents are supported to manage their own matters when possible. For example to manage their own money or their medication. Residents have the opportunity to attend house meetings whereby they can discuss the running of the home with staff on a more formal basis. Risk assessments are carried out where a resident is felt to be at risk for any given activity. These identify potential hazards to the service users safety and well being. It is recommended that risk assessments are completed in more detailed and are more comprehensive in the issues they cover. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 (adults 18-65) 10, 12, 13, 15 (older people) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are supported to develop their independent living skills, to develop and maintain relationships and to be involved in local community activities. Residents are provided with a varied diet of home cooked food. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 12 EVIDENCE: Residents gave good feedback on their support with pursuing leisure and social activities. There are some regular routines at the home and on the day of the visit the home owner accompanied a group of residents to a local pub. One of the residents described being supported by staff to go swimming and to attend a gym. Residents are going out and using community resources independently when they are able to and with support from staff when needed. It was reported that on Fridays the residents plan activities for the following week. A number of residents commented that they had enjoyed a long weekend break away and were looking forward to another. Residents are encouraged to make choices about the running of the home and their care. Residents confirmed that they are making choices and they gave examples such as choosing when to get up, when to go to bed, their meals, their daily routine, how to spend their day and this will include going outside of the home on their own if they have the skills to be able to do this independently. Residents reported that staff respect these choices. Staff also gave examples of how residents are making choices. Many of the residents are well able to express their needs and preferences and contribute to changes at the home. Residents have the opportunity to attend a residents meeting on a regular basis and are given the opportunity to complete surveys to give feedback on the home. Residents are encouraged to use and develop their independent living skills and one of the residents described being supported to learn new skills in an aim to move to more independent living in the future. Residents are supported to manage their own affairs when possible. Visitors are welcome in the home at all reasonable times. Residents families are welcome to attend parties at the home. In order to assess the meals and food provided the menus were checked, the kitchen was checked including food in storage and health safety in the kitchen and many of the residents were asked to comment on the food. Food was stored in good supply and stored safely. The majority of feedback on the food and meals was positive and one of the residents commented, “the food is really lovely and I can have what I want”. The only area for improvement commented upon by residents was that if they choose not to have what is on the menu for the main meal of the day then the alternative is something like soup or beans on toast and this is then their main meal of the day. The manager should review this with the residents. On the day of the visit residents were having homemade pie for lunch and were having a chip shop tea. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 (adults 18-65) 8, 9, 10 (older people) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are being supported with their personal, emotional and physical care needs but the home is failing to show this through care planning and appropriate record keeping. Medication is well managed on the whole. EVIDENCE: Residents gave good feedback on staff and how staff support them. When asked if staff were respectful of their privacy residents said that they were. Resident’s records included little information on their physical, emotional and health needs. Therefore it was difficult to establish what these were and whether or not they were being met at the home. The manager must ensure Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 14 that each of the residents has a comprehensive care plan which describes the resident needs in sufficient detail and details how these are to be met. This must include the residents needs with their mental health and emotional well being. Some review documentation showed that the residents are being supported with their health needs and during discussions with a number of the residents they were able to give examples of seeing a GP or nurse. Information on health appointments is recorded as part of the residents daily records and this makes it difficult to establish exactly what support they have been provided with and why. The manager must ensure that this information is recorded in a way which makes it readily accessible for those people who need access to it. Medication storage was checked and a random sample of administration records were checked. These showed that medication appears to be safely managed but that there are a small number of areas of practice which need to be addressed. These are to ensure that all staff sign the medication administration records at all times, guidance on the administration of ‘as required’ medication should be recorded on the medication administration records and staff should sign and date medication audits. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 (adults 18-65) 16, 18, 35 (older people) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Policies, procedures and practices are in place for dealing with complaints and for aiming to protect service users against abuse or neglect and systems are in place for dealing with allegations of abuse. EVIDENCE: The home has a complaints procedure which is time scaled appropriately and includes contact details for the Commission. The manager reported that residents have been provided with a service user guide and these include details for making a complaint. A copy of the complaints procedure is available to residents on the resident’s notice board. Residents spoken with about complaints said that if they weren’t happy about something then they would tell the manager. There have been no complaints made to the home since the last inspection. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 16 The home has an Adult protection procedure. This procedure provides information on adult protection and responsibilities for contacting relevant authorities. Care staff have been provided with training in adult protection. Staff who were asked about how they would respond to an allegation of abuse were able to provide appropriate answers. A record of key events is maintained for example incident reports and accident reports. These were checked and found to be maintained appropriately and there were no areas of concern identified. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 (adults 18-65) 19, 26 (older people) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is clean and safe and generally presented to a good standard although there is room for improvement in a number of areas. EVIDENCE: A tour of the premises was carried out which included all areas. The home feels welcoming and homely and resident’s bedrooms are personalised with some of Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 18 their belongings. Residents reported being happy with their bedrooms and all areas of the home. There are two communal lounges and the dinning area is in a conservatory extension. The environment is generally well maintained, however a tour of the home revealed that a number of areas requiring attention; • • • • • There is insufficient heating in the conservatory One communal toilet was malodorous and carpeting outside of this room needs to be replaced One of the resident’s bedrooms is in need of redecoration One of the resident’s bedrooms is in need of new carpet It is recommended that a dish washer is provided The home owner is reported to be investing in the maintenance of the property and is making improvements to the home on an ongoing basis. An audit of the home environment is carried out on a monthly basis and this identifies areas for refurbishment or repair and these areas are then acted upon. The home has health and safety practices and procedures which are aimed at ensuring the home is safe and clean and as free from hazards to the health and safety of service users and staff. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 (adults 18-65) 27, 28, 29, 30 (older people) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are supported by appropriately qualified and trained staff. Staff numbers are appropriate to ensure that the resident’s needs are being met effectively. Staff recruitment and selection practices are thorough and aim to protect residents. EVIDENCE: The manager has identified the training which staff have had and has identified staff training needs for individual members of staff and for the staff team as a whole. Staff training includes training on topics such as first aid, fire safety, adult protection, food hygiene and infection control. The manager has Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 20 attained a range of training packs for many other topics and is providing in house training for staff. Overall the level of staff training appears to be quite good. The care staff team consists of 11 staff and of these 8 have a National Vocational Qualification (N.V.Q) level 2 in care. This means that 75 of the care staff team have attained a relevant qualification and the home has exceeded the target for the workforce to be qualified to this level. Residents gave positive feedback about the staff including “staff are very kind”. Staff presented as caring during discussions and they were observed to be warm and friendly with the residents throughout the inspection. During discussion with a member of the staff team they reported feeling well supported. Throughout the visit there was frequent reference to good team work and a good team spirit. Staff turnover is low and therefore many of the staff have been supporting the residents for a significant period of time and have had the opportunity to get to know the residents well. There has been only one new member of staff since the last inspection. The records for the recruitment of this member of staff were checked. These showed that all relevant pre employment checks had been carried out before the person started working at the home. The manager should ensure that recorded staff meetings occur more frequently. This is to ensure that staff members have a regular forum to discuss issues that may effect the service provided to service users and the implementation of polices, procedures and practices within the home. Staff records and discussions with staff show that staff are not being provided with one to one supervision. It is a requirement that staff receive regular and recorded supervision. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 (adults 18-65) 31, 33, 35, 38 (older people) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is run in the best interests of the service users. There are however some areas for improvement. Procedures, practices and checks are in place which aim to safeguard and protect the health and safety and well being of service users and staff. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 22 EVIDENCE: The current manager has been managing the home for approximately 5 years. Residents gave very good feedback on the manager and one resident commented “The manager Ann is lovely and very good”. The home appears to be well run and well organised in a number of areas. However, there are some areas for improvement to the home particularly in relation to the lack of appropriate care planning and other information for residents as this is letting the home down in terms of evidencing the support provided to residents. Throughout the visit the manager was being drawn into dealing with issues which detract her from management duties. This was discussed with the manager and it is recommended that the manager’s daily tasks are reviewed. In addition to this the way in which the office is set up should be reviewed. Along with residents contributing to daily decision making in the home residents are also invited to comment on the home through residents meetings and through completing surveys on the home on annual basis. Residents manage their own money when appropriate. Where a resident needs support with managing their money then a record of all money they give in and take out is kept and receipts are kept for purchases whenever possible. A random sample of residents monies were checked and found to be well documented. Staff are provided with training in health and safety topics and the home has health and safety policies and procedures. The hot water supply is thermostatically controlled. However the manager was advised that hot water temperatures still need to be checked and recorded on a regular basis. Fire safety and health and safety practices are adopted. Records of fire and health and safety checks were checked and found to be up to date. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x 2 x 3 x 4 x 5 x 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 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 2 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 x 39 3 40 x 41 x 42 3 43 x 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kingsley House Score 3 2 3 x DS0000018906.V307481.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The registered person must ensure that each resident has a comprehensive care plan which accurately reflects the care needs of the residents for all aspects of their personal and health care. Residents should be consulted and encouraged to contribute to the development of their care plan. The registered person must ensure that when a resident is supported with a health issue or health related appointment that this information is clearly recorded in their records. The registered person must ensure that medication administration records are appropriately maintained at all times. The registered person must ensure redecoration, refurbishment and maintenance work as identified in the report is completed. DS0000018906.V307481.R01.S.doc Timescale for action 17/03/07 2. YA19 17 17/03/07 3. YA20 13 (2) 24/02/07 4. YA24 23 17/04/07 Kingsley House Version 5.2 Page 25 5. YA36 18 (2) 6. YA43 The registered person must ensure that staff are provided with regular and recorded supervision. 13 (4) ( c) The registered person shall ensure that water temperatures are checked regularly and maintain a record of this. 17/04/07 24/02/07 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. 2. 3. 4. 5. Refer to Standard YA9 YA17 YA37 YA37 YA36 Good Practice Recommendations It is recommended that risk assessments are more comprehensive and completed in more detail. The manager should review the choice of evening meal with the residents. The registered person should review the roles and responsibilities of the manager and the systems in place for administrative tasks. The manager should review the effectiveness of how the office is used. The manager should ensure that recorded staff meetings occur more frequently. Kingsley House DS0000018906.V307481.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 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 House DS0000018906.V307481.R01.S.doc Version 5.2 Page 27 - 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!