Inspection on 13/07/06 for Kingsley Nursing Home

This inspection was carried out on 13th July 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kingsley Nursing Home 26/05/09

Kingsley Nursing Home 04/05/07

Kingsley Nursing Home 28/02/06

Kingsley Nursing Home 26/07/05

Kingsley Nursing Home 07/12/04

Kingsley Nursing Home 22/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Kingsley Nursing Home 4 Trafalgar Road Southport Merseyside PR8 2EA Lead Inspector Mrs Claire Lee Unannounced Inspection 9.40 13th July 2006 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 Nursing Home DS0000044817.V295780.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 Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsley Nursing Home Address 4 Trafalgar Road Southport Merseyside PR8 2EA 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) 01704 566386 Kingsley Nursing Homes Ltd Mrs Barbara Evans Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social care Inspection. 28th February 2006 Date of last inspection Brief Description of the Service: Kingsley is a privately run home providing 25 places for older people who need nursing care. It is situated in a residential area of Southport with easy access to local shops, the town centre and public transport. The registered provider/owner is Kingsley Nursing Homes Ltd and the manager is Mrs Barbara Evans. The premises are detached and comprise of 2 buildings over 4 floors. The home has 21 single bedrooms (4 with ensuite) and 2 double bedrooms both ensuite. The accommodation is on the ground, first and second floor and a passenger lift provides access to all areas. Residents have the use of a call system with an alarm facility. Recreational space consists of a lounge and dining room/conservatory overlooking the front. Bathrooms although domestic in style have aids to assist those who are less independent. The home has well established gardens to the front and rear and there is also some car parking space. A ramp leads to the front door. The range of fees is between £468.65 (single room) to £473.80 with an ensuite facility. Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the unannounced inspection, a site visit took place at the home by an inspector over 2 days for duration of 14 hours. A partial tour of the premises took place and a number of the home’s care, staff and health and safety records were viewed. Discussions took place with 7 residents, 5 staff, the home’s financial administrator, manager and deputy manager. During the inspection 5 residents were case tracked (their care files were examined and their views of the home were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. Discussion also took place with 3 relatives. All the key standards were inspected and also previous requirements and recommendations from the last inspection in February 2006 were discussed. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents prior to the inspection and some were also left for relatives to compete at the time of the visit. Comments included in the report are taken from the survey forms and also during the site visit. What the service does well: The home presents a very pleasant relaxed atmosphere and staff were seen spending time with residents in the lounge and in their rooms. Visitors were popping in at various times of the day and a number of residents were enjoying the sunshine in the garden. The care is delivered by a stable workforce of staff who are enthusiastic and motivated. Residents are admitted to the home following a full needs assessment and this information is then used to form a plan of care. Care files viewed contained a detailed record of current health care provision and a resident said, “The care is always good and the staff are very pleasant”. Residents interviewed stated that they can see their GP at any time and staff respond quickly if a medical appointment is needed. Through discussion and observation it is was evident that residents are treated respectfully and that the routine in the home is based around individual wishes as much as possible. Those residents seen were appropriately dressed and staff were observed to assist residents with their personal care and also their lunch in a sensitive manner. Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 6 An activities programme enables residents to join in with musical entertainment, film shows, bingo, quizzes, Body Shop massages, manicures and fish and chip suppers. An outing to a local park is being arranged soon. A resident said, “The music is very good but you don’t have to join in if you wish not to”. The home is pleasantly decorated, bright and airy. All areas are subject to a programme of refurbishment and decoration. A number of bedrooms have been decorated and there are plans to install a walk in shower to improve the bathroom facilities. Residents and relatives were pleased with the overall maintenance of the premises. Areas seen were clean and tidy. The garden is attractive and has seating for the residents. The overall standard of training for staff has improved and a training matrix (plan of training) is now in place. Staff have a key worker role which enables them to get to know a number of residents in more detail and there was good evidence of carers being involved with the recording of the daily care. The management of the home is organised and the manager works closely with the owner and staff. A staff member said, “The manager is very kind and approachable”. Residents are asked for their views of the home on a regular basis and the manager draws up action plans to meet individual requests where possible. The owner, Mr Ralston, visits the home regularly to meet with residents and staff; this was confirmed during interviews held. A resident said, “Barbara (manager) always pops in and is very helpful in getting things sorted for me”. What has improved since the last inspection? What they could do better: Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 7 The home is required to review the overall standard with regards to meal times and include serving of hot drinks, choice and quality of foods served. This is in light of a number of comments received from survey forms and talking with residents. Several residents spoken to did not have any complaints regarding the catering. The latest copy of Sefton’s Adult protection procedure is available in the home and this should be used in conjunction with other adult protection information for staff. The home must continue with mandatory training for staff, first aid and food hygiene is now required. A record of induction must also be kept for new staff and include any external induction event attended. NVQ training should continue for care staff and it is strongly recommended that the manager undertake NVQ Level 4 in Management as part of her training programme. The manager confirmed that this would be arranged in the near future. Fire prevention equipment was safety checked earlier this year but the certificate for this could not be located. The home were also unable to locate the electrical certificate for the premises. Copies of both certificates must be forwarded to the Commission. This is a health and safety concern. 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 Nursing Home DS0000044817.V295780.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 Nursing Home DS0000044817.V295780.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Pre admission assessments help ensure that the home can meet the needs of the residents. EVIDENCE: With regards to written information for residents and relatives the home has a Service User Guide and Statement of Purpose. A copy of which is displayed in the entrance porch of the home. A number of survey forms returned to the Commission make reference to not all prospective residents receiving sufficient written information prior to admission. This was brought to the manager’s attention, as there may be instances when these documents are not being given out routinely. A resident interviewed was happy with the information given and felt that it gave a “Good picture of the home”. The manager completes an initial enquiry sheet for prospective residents and this is followed by an assessment of need. As part of the case tracking process 3 assessments were seen. These contained information with regards to health, Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 10 emotional, personal and social care. The assessment information is then used to form the basis for the plan of care. In addition to the assessment a ‘Life History’ (which is a brief outline of the person and their background) is also completed, the emphasis being on family arrangements and preferred hobbies. Social care assessments from external professionals are obtained where possible and there was evidence of these records and hospital transfers letters to assist in the assessment process. Standard 6 is a key standard to be assessed however the home provides long term care only and does not provide intermediate care. Some of the residents have lived at the home for a number of years. Kingsley Nursing Home DS0000044817.V295780.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents’ health, personal and social care needs are addressed in care plans and medicines are given according to the home’s administration policy. Residents are treated with respect and dignity. EVIDENCE: Residents have an individual care file and 5 files were viewed as part of the case tracking process. The care files are accessible for staff, they are organised and the information is easily read. Care documentation seen had also been reviewed regularly to ensure it was accurate and reflected any change in care or treatment. Survey forms make reference to residents receiving the care and support they need. Care plans detail health, personal, social and emotional needs and this was discussed in detail with regard to wound care and those who require referrals to external health professionals. Wound care is well managed; records indicate current treatments and regular contact is made with the tissue viability nurse (skin specialist) for advice. A phone call was made at the time of the site visit to request a visit for a new resident. It was noted that one care file did not contain a care plan for a resident who had Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 12 receiving medication for a recent condition. The manager was advised that a plan of care should have been formulated to advise staff of the resident’s care needs. Residents are approached for their consent to their plan of care and are advised of any changes in care provision. This was confirmed when talking with a number of residents. General risk assessments, including manual handling (mobility) instruction, are in place for residents who are at risk of falling or who require assistance with their mobility. Risk assessments for, nutrition, care of resident’s skin and for residents who wish to self-administer their own medicines had also been completed. Residents are weighed regularly to monitor any weight change. Comments from residents regarding the care include: “Staff are nice when giving help and care” “The care is fine” “The staff do their best” “I can see a doctor when I want” “I am in good hands” “I have made great progress since coming here, my physiotherapist visits and with the staff’s help I am much more confident. I feel so much better” The care files evidenced visits by doctors, chiropodists, physiotherapists and other community based staff. A relative said, “The staff call the doctor immediately, I don’t have to ask”. It was evident that the home has good links with external health professionals. A physiotherapist was providing instruction for a resident at the time of the site visit. Residents are able to self-administer their own medicines if they wish and sign a disclaimer for this practice. Discussion took place around residents who wish to self-administer controlled medication (medicines liable to misuse) and the staff are aware of the risks involved and how to manage this. The medicine sheets evidenced staff signatures following administration and residents interviewed stated that they receive their medicines on time. Wound dressings are recorded and signed by staff are being applied on wound care charts rather that on the medicine sheets. Medicines are administered from blister packs and the medicine trolley is locked and kept in the office when not in use. At the time of the site visit advice was taken from the Commission’s pharmacist with regard to the disposal containers for controlled medicines. The manager was advised accordingly of the preferred method. Residents interviewed were pleased with the standard of privacy and dignity offered to them by staff. A resident said, “The girls are polite and helpful”. The home had a pleasant atmosphere and there was good interaction between residents and staff. Residents’ preferred names are used and a resident commented that this “Made her feel at home”. Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 13 Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents are able to exercise choice and control over their lives but this needs to be improved in relation to the quality and choice of meals provided. EVIDENCE: The home has a very pleasant friendly atmosphere and the manager and staff have worked hard to provide a social programme to suit individual needs and preferences. Social activities include, flower arranging, bingo, quizzes, musician, Body Shop massages, manicures, fish and chip suppers, clothes parties and film shows. Social interests are recorded in the plan of care. Comments from residents included, “A singer comes who is very good” and “I don’t wish to join in prefer to stay in my own room, I can choose”. The hairdresser was visiting during the site visit and the ladies confirmed that this service was good. The manager is looking to arrange a social outing to a local park soon and the home has a lovely garden which residents and their visitors were enjoying. The home provides communication cards for residents whose speech may be affected. Residents interviewed were happy with the routine in the home and felt it was flexible enough to meet their individual needs. This was talked about in Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 15 relation to meal times and getting up in the morning. A resident said, “I like to get up later and this is never a problem”. The home offers Holy Communion and clergy visit from different denominations. This enables residents to continue to practice their own faith. Residents were sitting in the garden, lounge or dining room with their visitors. Some residents prefer to stay in their own rooms and staff respect this wish. Staff were observed spending time on a one to one and visitors were seen popping in at various times of the day. A relative stated that he is always made welcome by the staff. Residents are able to manage their own finances and the home’s administrator assist with financial arrangements when required. A financial record for one resident was viewed and this contained receipts of expenditures and a balance total. The home has details of the local advocacy service and contact is made with them when appropriate. With regards to meals served and mealtimes in general a number of residents/relatives stated that this could be improved. Comments from the survey forms and from the site visit included: “The meals are generally good and varied but I have pointed out that the actual quality of food is not that good i.e. the very cheapest of everything” “The food is not always tasty” “Sometimes like the meals in the home” “The staff sometimes forget what I cannot eat” “We don’t always get a morning cup of coffee when the staff are busy” “Sometimes the meals are not hot enough” “Don’t know what is on the menu at lunchtime but I do get asked at tea time” “I have not seen a menu and I would like one” “We are only asked what we would like at tea time” Several residents interviewed did however feel that the choice of meals was fine and they had no complaints. A resident said, “The food is very good”. The manager has completed food surveys in the past and an action plan was seen to address any requests from the residents. The menu was seen in the kitchen only and this did not evidence a choice of hot meals at lunchtime. Staff confirmed that an alternative would be provided on request. A recent environmental health inspection instructed kitchen staff to ensure cleaning schedules are completed. A cleaning record was seen for July and this had generally been completed. Fridge and freezer temps are recorded during the week but the readings were missing for a number of weekends. The manager must look to improve the overall standard of catering, serving of food/drinks and ensure residents are given a menu thus enabling them to make a choice as to what they would like to eat. The home has 3 cooks, one works full time and had an advanced qualification in food hygiene. Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 16 There was a good supply of fresh fruit and vegetables and the freezers were well stocked. Frozen meat is purchased. Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents and relatives have confidence that their concerns will be dealt with. Abuse policies and procedures are in place to protect the residents. EVIDENCE: The home has a complaint procedure and residents interviewed were aware of who to go to should they have a worry or wish to make a complaint. The following comment was made, “I do always approach staff as appropriate with any problems”. The complaint log was examined and no complaints have been received since the last inspection. Staff interviewed explained what they would do should a resident or a relative wish to make a complaint. The staff training matrix evidenced abuse awareness training for a number of staff and staff interviewed had an understanding of how to report an alleged incident. The home has an abuse policy and also the latest copy of Sefton’s Adult Protection Procedure. This should be made available for all staff as it was hard to locate. There have been no referrals to the POVA (Protection of Vulnerable Adults) list. Recruitment procedures for staff are discussed under Standard 29 of this report. Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 and 26 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents live in pleasant, safe, comfortable and well-maintained surroundings. This contributes to a good quality of life for them. EVIDENCE: Kingsley consists of two houses that have been joined together. Accommodation is available on all 3 floors, the laundry room, staff room and storage space situated in the basement. A relative said, “The home is comfortable and nice to visit”. The bedrooms are gradually being refurnished and decorated and general improvements to the décor are being made to all areas, this should continue. Work to a ground floor room was in progress. Residents interviewed were pleased with their bedrooms and the standard of furniture provided. Rooms Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 19 seen were clean and residents had their personal belongings such as ornaments, pictures and electrical equipment. The maintenance man carries out general day to day jobs and residents were satisfied with the overall upkeep of the home. The owner is looking to extend the home in the future and plans for this work are with the architect. The areas most in need of attention are the bathrooms and kitchen. The kitchen is small and domestic in style. The staff are currently only using 2 bathrooms located on the ground and first floor and the manager is looking to convert 1 bathroom on the top floor in to a walk in shower. This is a good idea as it would give the residents more choice and improve the overall bathing facilities. The bathrooms seen were clean and the records seen for the hot water temperatures indicated that hot water is delivered to a safe temperature. Bathrooms have bath chair hoists and a toilet has a raised toilet seat to assist residents. The home also has 3 hoists and 4 height adjustable beds to assist residents who are less independent. A number of wheelchairs seen did not have footrests in place however this was corrected at the time of the site visit to ensure the safety of the residents. The laundry room was viewed and this had sufficient equipment to enable the laundry assistant to undertake her work efficiently. COSHH data is available on products in use and staff were using gloves and aprons. Emergency lighting is provided throughout the home and subject to a monthly in house check. Records seen were up to date. Discussion took place with a relative with regards to not being able to open a bedrooms window in the home in full. Window restrictors are in place in accordance with guidance from environmental health and further advice regarding their use can be obtained from this department. The gardens are well maintained with attractive flowers beds and hanging baskets. The gardens are accessed by a ramp or steps. A resident commented on the attractive front garden and how much she enjoys sitting out with her visitors. Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. An induction must be given to all new staff and training is required in a number of safe working practices to ensure staff have the skills and knowledge to undertake their work. Recruitment practices are robust. EVIDENCE: At the time of the site visit 24 residents were accommodated. The off duty was seen for the month of July 2006 and this evidenced sufficient numbers of staff on duty to care for the residents. A resident said, “The carers are extremely good”. A family were visiting the home with regard to choosing accommodation and they were greeted warmly by the staff member. The home does not employ agency staff; the permanent staff cover any outstanding shifts. There are no staff vacancies. On the second day of the inspection the manager was on duty with the deputy, a registered nurse, 4 carers, cook, kitchen assistance, cleaner, laundry assistance and maintenance man. At night the home is staffed by a registered nurse and 2 carers. Residents stated that the home had sufficient staff on duty and that generally staff answered the call buzzers promptly. A resident said, “Staff may take longer to respond when the home is busy but that is unavoidable”. Completed survey forms refer to residents and relatives being pleased with the overall care given and the helpful nature of the staff. The following comment was made, “Generally staff are very caring and try to do their best to help us feel comfortable”. A resident and relative said, “The staff are very kind”. Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 21 The home has 2 domestic staff and residents were generally pleased with the cleanliness of the building. Comments included: “My room is cleaned most days” “The girls come in to tidy up” “Have had occasions when it was necessary to ask for the room to be kept cleaner” 4 staff files were examined for recruitment purposes and only 2 new members of staff have started since the last inspection in February 2006. These files contained a completed job application form, 2 written references and evidence of a POVA check. One reference was not dated one staff file required a photograph for verification purposes. The manager stated that this would be rectified this week. The home is awaiting confirmation of one employee’s CRB and an up to date list was seen of all other police checks on file. The other 2 files had a number of requirements but these were raised at the previous inspection. Recruitment practices have now improved to ensure all the necessary documentation is in place prior to an employee commencing work. It was however noted that several application forms lacked staff signature as the back page was missing. This was brought to the manager’s attention to ensure complete application packs are given to staff. The home is now implementing a training programme, which includes the mandatory courses – manual, handling, cross infection, food hygiene, first aid and fire prevention. The manager confirmed that a number of staff require food hygiene and first aid and staff files viewed evidenced that this training is required. Manual handling training was given in June 2006 and Health and Safety in January 2006. A course in cross infection is being offered to staff. As part of the induction for new staff a copy of a number of the home’s policies and procedures are provided in the staff files and staff sign to say they have read and understood the document. An external induction day had been arranged for 2 staff members however 2 others had not received an induction. The induction process must be developed to ensue staff have the necessary knowledge to undertake their work and are aware of their responsibilities. The manager arranges other course relevant to the care of the older person and a training matrix is available for staff. NVQ at Level 2 and Level 3 is ongoing for care staff and the home is working towards the 50 required in this qualification. A staff member interviewed discussed further NVQ studies that she wishes to undertake and the good support received from the manager regarding this. Staff at the home have a key worker role (extra responsibilities assigned for a number of residents) and they expressed the view that this role enables them to get to know the residents better. Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 22 The pre inspection questionnaire completed by the manager provided details of the registered nurses PIN (personal identification numbers) to evidence registration with the NMC (Nursing Midwifery Council). These were current. Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Not all certificates for the maintenance of equipment were available to promote and protect the health and safety of the residents. EVIDENCE: The manager is Mrs Barbara Evans. It was evident during the site visit that Mrs Evans works closely with the staff and staff interviewed described her as “Fair”, “Good Manager”, “Approachable” and “Supportive”. Mrs Evans is a registered nurse and has many years experience in care. It is strongly recommended that Mrs Evans commence NVQ in Management as part of her management programme. Staff confirmed that they attend staff meetings and that the Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 24 registered provider also comes regularly to the home to meet with them. It was evident that the home has a committed team of staff. With regards to reviewing the service survey forms are sent out by the manager on a regular basis. The most recent received were viewed, positive comments were noted. The manager undertakes a periodic review of the homes’ policies and procedures to ensure they are in line with current legislation and the owner conducts a monthly visit of the home; a detail report is then forwarded to the Commission each month of his findings. As previously stated assistance is provided by the home’s administrator for the residents with their financial affairs. Any costs not covered by the fee rate are also recorded and an accurate record of expenditures kept. This was viewed in relation to newspapers, hairdressing and chiropody. Staff receive supervision and a record was seen in four staff files of these meetings. Staff stated that the sessions were beneficial and were held regularly. The home’s accident book is used to record any untoward event that may affect a resident. Forms examined were detailed and had been signed and dated. With regards to maintenance certificates the home were unable to locate a safety certificate for fire prevention equipment. Contact was made with the home’s engineer who confirmed that a site visit took place in March 2006. The electrical certificate for the premises could not be located and the provider was contacted with regards this. This is a health and safety concern for residents and staff. Both certificates must be forwarded to the Commission and be made available for future inspections. Certificates for the gas, lift, hoists and portable appliances were in date. Fire prevention training was given to staff in March 2006 and the last drill was conducted earlier this month. Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 X 2 Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP15 Regulation 16 Requirement The manager must improve the standard of meals and ensure all residents receive a well balanced diet. Residents must be given a menu and provided with a choice at meal times. The home must provide staff with mandatory training The home must provide staff with a structured induction The home must forward to the Commission a copy of the safety certificate for fire prevention equipment The home must forward to the Commission a copy of the electrical certificate for the premises Timescale for action 13/08/06 2. 3 4 OP30 OP30 OP38 18 18 12/13 13/09/06 13/08/06 13/08/06 5 OP38 12/13 13/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 27 1. 2. 3. 4. 5. 6. 7. OP15 OP18 OP19 OP19 OP29 OP28 OP31 To meet the requirements/recommendations from the most recent environmental health report and to ensure fridge and freezer temperatures are recorded each day To ensure staff are familiar with Sefton’s Adult Protection Procedure To continue with the refurbishment and decoration plan for the home (to include plans to extend the kitchen). To have a walk in shower installed in the top floor bathroom. To ensure complete application forms are given to staff To continue with the NVQ programme for care staff It is strongly recommended that the manager undertake NVQ Level 4 in Management Kingsley Nursing Home DS0000044817.V295780.R01.S.doc Version 5.2 Page 28 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 Nursing Home DS0000044817.V295780.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. 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