Inspection on 16/10/07 for Kingsmead Care Centre

This inspection was carried out on 16th October 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 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

Kingsmead Care Centre 21/03/07

Kingsmead Care Centre 09/11/05

Kingsmead Care Centre 18/07/05

Kingsmead Care Centre 25/05/04

Similar services:

Wingham Court

Old Hastings House

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Kingsmead Care Centre Crawley Road Roffey Horsham West Sussex RH12 4RX Lead Inspector Mrs D Peel Unannounced Inspection 10:00 16 October 2007 th X10029.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 Kingsmead Care Centre DS0000024246.V347603.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. Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsmead Care Centre Address Crawley Road Roffey Horsham West Sussex RH12 4RX 01403 265335 01403 269944 kingsmead@sussexhealthcare.org 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) Dr Shafik Hussien Sachedina Mr Shiraz Boghani Mrs Judith Alison Williams Care Home 34 Category(ies) of Physical disability (34), Physical disability over registration, with number 65 years of age (17) of places Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A maximum of 34 service users may be accommodated. Kingsmead House Unit - A maximum of 25 service users in the category physical disability (PD) aged 40-65 years of age may be accommodated of whom 17 service users in the category physical disability elderly (PD)(E) may be accommodated. Kingsmead Haven Unit - A maximum of nine service users in the category physical disability 18-65 years may be accommodated. 21st March 2007 3. Date of last inspection Brief Description of the Service: Kingsmead Care Centre is a mixed care home registered to offer health, personal and nursing care to up to 34 service users in the categories specified above. The establishment is located in the village of Roffey, on the outskirts of Horsham, West Sussex. It comprises of a two storey main building in which 25 residents are accommodated, aged 40-65. Accommodation in the main unit is provided in twenty-one single rooms and two double rooms. There is a ramped access to the ground floor and a passenger lift provides access to the first floor. Several rooms on the ground floor have direct access to a garden area. Facilities include an activities room and a two lounge /dining rooms. A smaller attached unit, Kingsmead Haven accommodates 9 residents with physical disabilities aged 18-65, in single well-equipped rooms. Sussex Health Care Group owns the service. The responsible individuals on behalf of Sussex Health Care are Dr S. Sachedina and Mr S Boghani. The Registered Manager is Mrs Alison Williams. Fees range from £593 to £3000 based on assessed needs of people who live at the home. Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Mrs Diane Peel carried out this unannounced visit to Kingsmead Care Centre on the 16th October 2007. During this visit the intended outcomes for 26 standards were assessed; these included the key standards for care homes providing a service to older people and younger adults. Prior to the visit to the home previous inspection reports and information gathered about the home since it was last visited in March 2007 were reviewed. Ten Have Your Say surveys were returned to CSCI by people living at the home, eight surveys were returned by relatives and friends and seven surveys were returned by staff prior to the visit to the home. All this information was used to inform the inspection process. The Annual Quality Assurance Assessment (AQAA) was returned to The Commission for Social Care Inspection (CSCI) prior to this visit to the home and this was used to address areas of improvement and further improvements with the manager. On the day of the visit there were twenty nine people living at the home and during the course of the visit the inspector met the majority of residents and spoke with those who were able to converse with the inspector in either in the privacy of their bedrooms or in the communal areas. A case tracking exercise for four people living at the home was undertaken to look at how the assessed needs of this group of residents with diverse needs were being met. Staff were spoken with during the visit and observed during their interaction with people living at the home. What the service does well: Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 6 Kingsmead Care Centre has a friendly homely atmosphere and the staff were observed to take the time to communicate with people in a polite and meaningful manner. There is some good information available for people to refer to when looking to choose a care home to move into. People returning Have Your Say surveys to CSCI commented about the “kind, caring staff who also make visitors welcome offering “tea and coffee and sometimes plates of sandwiches.” One visitor said, “ I have no complaints regarding the service given. The general feeling of the home is one of a happy and friendly place. “ A relative commented “residents are entertained with events and outings to help keep some normality in their lives.” The manager is approachable and wants to provide a good service to the people who live at the home. What has improved since the last inspection? What they could do better: There must be some consultation with people living at the home about the variety and choices of menu. No positive comments were made about food by people living at the home who spoke about “repetitive meals” which were often cold especially at suppertime and the “same choices” for alternatives to the main meals. The deployment of staff at mealtimes must be managed better. Meal times are not well planned with some people who need assistance having to wait for their meal whilst others assisted, resulting in their meal going cold. Clinical waste bins in sluice rooms must have lids and are ideally foot pedal operated. Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5,6 Older People 1,2,3,4, Younger Adults People who use the service experience good outcomes in this area. People, who come to live at the home and their families, have information available to make an informed choice about where they want to live and people’s needs are assessed before they move to the home, so that they know that the home can meet those needs. EVIDENCE: Kingsmead Care Centre has a Statement of Purpose and Service User Guide, which provide good information about what the home has to offer to Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 10 prospective people who may want to use the service. There is also a briefer leaflet available for basics information and the organisation has its own website which provides information about all its care homes. During the visit to the home a resident who said that they had recently moved into the care home spoke about how they had been to Kingsmead and another home to have a look around and had chosen Kingsmead because “it seemed friendly, was homely and didn’t have any unpleasant smells”. Information about the home was observed to be present in the entrance to the home and the statement of purpose was observed to be on display. Seven out of the ten people living at the home who returned Have Your say Surveys to CSCI reported that they has enough information about the home before they chose to move in. Two people said that they didn’t have enough information and one person said that their daughter had chosen the home for them. Another person said, “ my son came to view the home as I was in hospital. He found it was the best of six homes he visited. When I came here I was satisfied that he had chosen well.” The home has an admission procedure, which includes an assessment of need prior to moving into the home and the opportunity to visit with the possibility of overnight stays. The care records of four people were looked at during this visit, three for people who live in Kingsmead Haven and one person who lives in Kingsmead main unit. Records showed that a needs assessment are carried out and for those people being funded by a local authority there was a care management needs statement. Nine Have Your Say surveys were returned to CSCI by relatives of which six stated that the home always meets the needs of their relative living at the home and the other three stated that their relatives needs were usually met. Information provided in the homes Annual Quality Assurance Assessment (AQAA) returned to CSCI prior to the visit to the home reported that there are both male and female care staff working at the home of various ages between eighteen years of age and sixty five years of age and who are from diverse social, cultural, and religious groups providing a service to people who have a range of diverse physical, emotional and religious and cultural needs. The home does not offer intermediate care. Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 11 Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Older People 6,9,16,18,19,20 Younger Adults People who use the service experience good outcomes in this area. Care planning systems are regularly updated and they give clear information to assist with all aspects of health, personal and social care needs so that the changing needs of people living at the home can be monitored. EVIDENCE: Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 13 The care records for four people were viewed during this visit. The manager informed the inspector that care plans and records were in the process of being transferred to a new standard format required by the organisation. The care plans observed showed that the differing needs of residents have been addressed and that care staff have information about how these needs should be met. Care plans observed had been reviewed regularly and discussion with a qualified nurse on duty confirmed that it is the nurses who complete daily evaluation sheets for each resident at the end of each duty. A member of staff returning a Have Your Say survey to CSCI commented, “care plans are updated monthly but any new information is also recorded.” Care records demonstrated that people living at the home have access to the normal health care services and during the visit it was observed that a Doctor arrived at the home to visit a resident who was unwell. This person was assisted to the privacy of their room for the consultation with the Doctor. Out of the ten have Your Say Surveys returned to CSCI three people said that they always received the medical support that they needed, six said that they usually received enough support and the other person felt that they ought to have more assistance with medical support. The home has a risk policy, which considers freedom of choice and states “freedom within reason to take risks.” Care records viewed were observed to include individual risk assessments. The home has a medicines policy and the nurse on duty confirmed that it is only qualified nurses, which administer medication. At lunchtime a nurse was observed to take out the medication to people living in Kingsmead. The medication was being stored in a lockable metal trolley. The nurse was observed to take medication to each individual and ensure that they took the medication before they returned to the medication record sheets to sign for the administration of the medication. Medication records observed on the metal trolley did not show any unaccounted for gaps; a code was being used to explain why any person had not had their medication. Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,12,14,15 Older People 12,13,15,17 Younger Adults People who use the service experience adequate outcomes in this area. People living at the home are encouraged to maintain contact with their family and friends and the activity programme is flexible to cater for individual residents abilities and to offer variation to daily living, however the variety and choices of food are not satisfactory and the deployment of resources must be improved so that people enjoy their meals and mealtimes. EVIDENCE: Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 15 From discussion with people living at the home during the visit and from feedback in Have Your Say surveys returned to CSCI from people living at the home and from relatives, the home is reported to be run in a flexible manner and visitors are made welcome. A relative said, “ There seems to be good flexibility.” There is an activities programme, which people can choose to take part in and activities co-ordinators are employed to support people with activities inside and outside the home. On display in the hallway leading to Kingsmead nursing area of the home was a schedule of events/activities, which included: current affairs, art/painting, outings, crafts, quizzes, reminiscence, News, and Bingo. In the Kingsmead Haven area there was evidence that people have activities to suite their needs. Some of the people living the Kingsmead Haven part of the home also go out to college and it was observed that a number had certificates of achievement from college courses displayed in their bedrooms. One relative returning a survey to CSCI said “ All sorts of things happening for those able to participate (and stimulation for those who cannot).” Another relative commented “ Full 24/7 attention, providing care and activities to stimulate.” Out of the ten Have Your Say surveys returned to CSCI by people living at the home, seven reported dissatisfaction with the choices and repetitive menus at Kingsmead Care Centre. People said: “ So repetitive. No different things, same meals week after week. “The food is ok but more choices would be good. Too much of the same things every week, very repetitive”. It’s a little repetitive. Same deserts all the time, winter and summer. Not much choice.” “They are always the same each week but on different days.” The inspector joined people for the main meal of the day in one of the dining areas in Kingsmead for lunch. The menu had been available in the morning and stated that it was chicken pie, broccoli, swede and new potatoes followed by pear crumble and cream. However the broccoli had been replaced by brussel sprouts and the potatoes were potato wedges. The printed menu had not been changed. People being served softened diets were not told the change of the vegetables and may have not liked brussel sprouts. Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 16 A person living at the home who spoke with the inspector in the privacy of their room commented upon how good the menu looks on paper but in reality its not the same with repetitive choices and food being served as replacements to what is on the menu. They also commented that meals at suppertime were often cold. Some people needed assistance to eat the meal and the deployment of staff at lunchtime did not allow for everybody to eat their meal without it becoming cold before they were attended to. This matter is unsatisfactory and was discussed with the manager as an area, which must be improved. There must be some consideration given to the deployment of resources at meal times. The food was brought in a hot trolley, which the staff did not plug in. They took food out on to the tables, which went cold. All the deserts, which should have been at least warm, were cold by the time people got around to eating them because they were put on the tables before people had eaten their main course. All residents were brought to the dining area for a meal when there was insufficient staff available to assist all those people who needed help at the same time. Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Older People 22,23 Younger Adults People who use the service experience good outcomes in this area. The complaints procedure enables those using the service to have the confidence that any complaints will be taken seriously and responded to. Arrangements are in place to protect people using the service from being place of harm or abuse. EVIDENCE: The homes complaints procedure is on display in the home and is available in pictorial form. CSCI has not received any complaints in respect of this service since the last visit to the home. The AQAA (Annual Quality Assurance Assessment) received prior to the visit to the home recorded that seven complaints had been received by the manager, three of which had been upheld all seven dealt with within 28 days. Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 18 The complaints record examined during the visit to the home, demonstrated that complaints had been responded to appropriately, outcomes recorded and copies of letters kept. Nine out of the ten people living at the home who returned surveys to CSCI reported that they knew how to make a complaint and one person reported that they didn’t. All relatives returning surveys said that they knew how to make a complaint. The home has its own safeguarding adults procedure, which it uses in conjunction with the West Sussex Multi Agency Adult Protection Procedures. The manager had been on a recent seminar to bring her up to date with the revised multi agency procedures. Two safeguarding adults referrals had been made directly by the home in the past year, which had both been investigated appropriately. Both matters were found to be unsubstantiated. The manager confirmed that safeguarding adults is covered during staff induction and then further training is provided for all staff. Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Older People 24,30 Younger Adults People who use the service experience adequate outcomes in this area. People living at the home have a comfortable, homely, well-maintained environment to live in but improvements to the disposal of clinical waste in sluice rooms would lessen the risk of spread of infection. EVIDENCE: Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 20 Kingsmead Care Centre provides a comfortable environment for the people who live there. Since the last visit to the home the loft space has been redecorated and cleared to provide more storage space and a redecoration programme has commenced. Information provided in the AQAA prior to the visit to the home confirmed that safety checks and equipment had been carried out. Records of maintenance of hoists were sampled during the visit to the home along with the checking of electrical equipment and equipment to be used in the event of a fire. Bedrooms were sampled at random and all communal areas, bathing faculties and sluices were visited. It was observed that there are still some service users bedrooms, which remain without a lockable door so that they can be secured when away from the home or after a death at the home. This matter has already been identified as an area of improvement to be made in the AQQA completed by the manager prior to the visit to the home. When visiting the sluice rooms it was observed that none of the clinical waste bins had lids on them. This is a poor infection control matter and a requirement has been made that all waste bins to be used for clinical waste must have a lid and foot opening operating system. Other matters of infection control were discussed with the manager who has agreed to address the issues. Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Older People 32,34,35 Younger Adults People who use the service experience good outcomes in this area. Recruitment procedures safeguard and protect residents at the home and staff receive training to support them in carrying out their jobs. EVIDENCE: At the time of the visit to Kingsmead Care Centre there were twenty people living in the Kingsmead main area of the home and nine people living in Kingsmead Haven. Whilst Kingsmead Haven was well staffed there seemed to be a problem at lunchtime in the main area of the home where older people live. This resulted Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 22 in people who needed assistance with their meal having to wait and their meal getting cold. This issue was discussed with the manager who has agreed to look at the deployment of resources at meal times so that everybody’s needs are met. Information provided by the manager prior to the visit to the home reported that 14 staff have an NVQ level 2 or above that there are four other staff working towards an NVQ level 2 or above. The records of five staff were observed during this visit to the home. They were observed to include evidence of Criminal Record Bureau (CRB) and Protection of Adults (POVA) checks. A job application was on file, two written references (for those people employed after 2002), photograph, proof of the person’s identity and completed equal opportunity monitoring forms and health declaration forms. Induction, supervision and training records were in place, which evidenced a commitment to the training programme for staff. Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 24 31,33,35,38 Older People 37,39,42 Younger Adults People who use the service experience good outcomes in this area. People living at the home and their relatives can be confident that the manager wants to run the home in the best interests of the people that live there, but to achieve this must continue to improve the home and address areas of improvement identified at this visit so that people have a varied appealing diet which they can enjoy and so that they are not at risk from unsatisfactory storage of clinical waste. EVIDENCE: The manager has the required qualifications and experience to run the home. Since the last visits to the home by CSCI she has undertaken the fit person process carried out by CSCI. People returning surveys to CSCI had positive things to say about the manager and the running of the home. They included: “the new manager is very approachable and responsive.” “this is a well run home with very good staff headed by a caring manageress.” “ lovely manager, very helpful and supportive. Regular staff meetings are held for both the qualified nurses and other staff working at the home and meeting minutes sampled referred to safe working practices, how to respond to complaints, reporting incidents to CSCI, duty rotas and the introduction of end of life palliative care programme. Staff records showed that staff are supported though appraisal, supervision and training to work safely and competently. Staff returning Have Your Say surveys to CSCI reported that they had regular access to the manager. The home has a quality assurance system, which includes surveying people who live at the home; their relatives and other interested parties. Examples of these were observed during the visit to the home and demonstrated that the manager had responded to any negative comments or suggestion of how things could be improved. Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 25 The organisation encourages people living at the home to manage their own finances but for the majority it is their relatives who take responsibility. The organisation continues to manage some people’s money through an “imprest account” where each person gets a monthly statement showing the balance of their transactions. Records of transactions are recorded and receipts kept. Information provided in the AQQA supplied to CSCI prior to the visit to the home demonstrated that annual safety inspections are undertaken on equipment and utility supplies. These were sampled at random and found to be correct. Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 2 X 3 3 4 3 5 3 6 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 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 3 37 3 38 2 Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP15 OP27 YA17 YA33 Regulation 16.2 (i) Requirement There must be a varied, appealing, wholesome and nutritious diet and deployment of staff at meal times must ensure that all service users who need assistance have their needs met. Timescale for action 01/12/07 2 OP26 OP38 YA30 YA42 16.2 (k) Clinical waste bins must have lids. 01/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kingsmead Care Centre DS0000024246.V347603.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. Kingsmead Care Centre DS0000024246.V347603.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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