Inspection on 29/11/07 for Kingstone House

This inspection was carried out on 29th November 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kingstone House 21/10/09

Kingstone House 31/05/06

Similar services:

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Insight - Eastchurch

Southfields

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Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Kingstone 121 London Road Burgess Hill West Sussex RH15 8LU Lead Inspector Nigel Thompson Key Unannounced Inspection 29th November 2007 10:00 Kingstone DS0000066070.V355859.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 Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingstone Address 121 London Road Burgess Hill West Sussex RH15 8LU 01444 245063 01444 258534 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) springmeadow@ilg.co.uk ILG Ltd Mrs Anna Theresa McGowan Care Home 20 Category(ies) of Learning disability (20), Learning disability over registration, with number 65 years of age (20) of places Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of service users accommodated should not exceed 20 at any one time. 31st May 2006 Date of last inspection Brief Description of the Service: Kingstone House is a care home registered to accommodate up to twenty Service Users with learning disabilities. The Registered Provider is Independent Living Group (ILG) and the Registered Manager is Anna McGowan. The home is made up of three detached properties located next door to each other. Kingstone has the capacity to accommodate twelve people and Cleveland’s comprises of three 2-bed independent apartments, each with their own kitchen, sitting/dining room and bathroom. To the rear of these properties is The Lodge, which houses two self-contained flats. All of the accommodation is situated a short walk from Burgess Hill’s town centre, and therefore is accessible to all community facilities, including rail and bus stations. Each service user has their own bedroom complete with en suite toilet facilities, some with showers. In addition there is also a large walk-in shower on the ground floor of Kingstone. Kitchens, dining rooms and lounge areas are well maintained and decorated to a high standard. The home is also in the process of developing an activity room at Kingstone. External grounds are enclosed for security purposes and consist of a tarmac area and a small lawn with seating. Information about the service, including the Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The current range of fees, as of 28 November 2007, is £900 - £2,000 per week. Additional charges are made for personal items, such as; toiletries, chiropody, hairdressing, activities, transport and holidays. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over five and a half hours in November 2007. It found that the majority of the key National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was satisfactory. There have been significant changes, regarding the ownership of the service since the previous inspection. The registered provider at that time was Evesleigh Care Homes. They were superseded by ILIACE, which soon afterwards was itself taken over, in April 2007, by the Independent Living Group (ILG) Several incidents, affecting the well being of service users have also been reported during this period and these were closely looked into as part of the inspection process. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. Service users observed and spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. On the day of the inspection there were twelve service users living at the home. The inspection process involved a tour of the premises, observation of working practices and examination of the home’s records and documentation. It also included discussion with four service users, three member of staff, one visitor to the home, the registered manager, the deputy manager, the appointed manager at Cleveland’s and the area manager. The focus of the inspection was on the quality of life for people who live at the home. What the service does well: Service users at Kingstone clearly benefit from having a competent and experienced manager and a dedicated staff team who are evidently committed to providing a consistent and high quality level of care. Staff work closely with service users and have developed a sound understanding of their individual care and support needs. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 6 The relaxed and welcoming environment has evolved over several years and reflects the stability and commitment within the staff team and the open and inclusive management style. Service users are enabled and supported to make decisions about their lives. They are involved and regularly consulted on many aspects of life in the home, including menu planning and activities. What has improved since the last inspection? What they could do better: The current admission procedure, including the assessment process, should be reviewed to ensure the direct involvement of the registered manager in future admissions to the home. A clear, concise and accessible complaints procedure must be developed and implemented, as discussed, for the benefit of service users’ relatives and other visitors to the home. It is important that all parts of the premises are well maintained and kept in a good state of repair and therefore the badly stained carpets throughout the home must now be replaced. The current inadequate quality assurance systems should be reviewed and improved, by seeking the views of service users’ relatives and other visitors to the home. Information about the home and services provided, made available to prospective service users, their relatives and representatives, including the ‘Service User Guide’ should be reviewed and updated to reflect the current situation within the home. Kingstone DS0000066070.V355859.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. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The current admission policy and procedure does not ensure that service users are routinely admitted on the basis of a full needs assessment, undertaken by people competent to do so. Consequently prospective service users do not always know that the home is able to meet their individual care and support needs. EVIDENCE: There have been several people admitted to Kingstone House and Cleveland’s since the previous inspection. Information relating to the home, including an updated ‘Statement of Purpose’, is made available to all prospective service users, their relatives and associated care managers. However, as discussed with the manager, the ‘Service User Guide’ must be reviewed and amended to reflect the current situation within the home. The manager confirmed that the service continues to maintain a good working relationship with the local Community Learning Disability Team (CLDT), who Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 10 consequently have a sound understanding and awareness of the suitability of the home and the range and quality of the services provided. Following a referral to the home, representatives from the organisation’s Placement Team will visit the prospective service user and carry out a full preadmission assessment, including any personal and emotional care and support needs, mobility issues, social and cultural needs and family involvement. However, despite being the person best suited to assess the suitability and compatibility of prospective service users, it was evident, during the inspection, that the manager is not routinely involved in the assessment process. In a recent case where a placement subsequently broke down, the manager confirmed that she had not been directly involved in all stages of the admission procedure. It was also evident from documentation examined, that the preadmission assessment had not been fully completed and vital information, including significant behavioural issues and peer group compatibility, had not been recorded. Through case tracking, it was evident that following a rapid deterioration in the service user’s psychological condition there was an increase in severe challenging behaviour, which seriously impacted on other service users within the home. Despite the concerted efforts of the manager and support staff, a decision was taken that Kingstone House was no longer able to meet her complex care and support needs. Following discussion with the manager and area manager, it is recommended that the current admission procedure be reviewed to ensure the direct involvement of the registered manager in future admissions to the home. As well as being invited to visit the home to look around and meet with existing service users and staff, where appropriate, prospective service users have the opportunity to stop overnight before moving in. The manager confirmed that all new service users undergo a flexible trial period at the home, during which time their suitability and compatibility are monitored and it is established whether their identified care and support needs are able to be met. In contracts that were examined it was evident that individual agreements had been signed and dated by the service user themselves or a relative or representative on their behalf, the manager and the service manager. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users’ care plans enable staff to meet assessed needs in a structured and consistent manner and individual plans, including risk assessments reflect changing support needs. Systems for consultation and participation remain effective and service users are treated with respect and are encouraged and enabled to make decisions about their day-to-day living. EVIDENCE: Staff spoken to during the inspection confirmed that, despite the variable and limited verbal communication of certain service users, effective and regular interaction and consultation takes place constantly throughout the home. This was evident from direct observation of staff supporting service users in a professional, sensitive and respectful manner. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 12 The manager confirmed that service users themselves, their key worker and, where appropriate, a relative or representative have the opportunity to be involved in regular care plan reviews. Support plans that were examined, including behavioural guidelines and risk assessments have evidently been reviewed, as required, since the previous inspection. Written in the first person, the comprehensive plans, including a detailed ‘Personal Profile’ are clearly linked to the individual’s current needs assessment. As well as containing detailed guidance for staff on how to meet service users’ care and support needs in a structured and consistent manner, the majority of plans also contain a full and comprehensive ‘Health Action Plan’. The manager confirmed that all staff are expected to sign to confirm that they have read and understood the guidelines and associated risk assessments. Following discussion with the manager, it is recommended that a contents or index be developed and implemented for each care plan to ensure information is more readily accessible. Independence and individuality is evidently encouraged and promoted within the home and is reflected in the personalising of service users’ rooms, the choice of bedclothes and colour schemes and individual preferences for occupational and leisure activities and menus. This was confirmed by service users, spoken with during the inspection: ‘I chose the colours for my room and my duvet cover and curtains. It’s a nice room’. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are enabled and supported to maintain contact with family and friends as they wish and effective links with the community enrich their social and educational opportunities. Service users benefit from appropriate recreational and leisure activities and menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: The recreational and leisure interests of service users are identified and recorded in their individual care plan and they continue to be supported to access activities and facilities, reflecting their individual needs and abilities. A weekly activities programme has been developed and implemented for each service user, a copy of which is displayed in the office. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 14 Community participation remains a focus in the home and service users are evidently encouraged and supported to visit the cinema, theatre, shops and other local amenities. The manager confirmed that, where appropriate, service users’ family links are encouraged and supported, however not all service users have regular family contact. Visiting to the home is largely unrestricted and relatives and friends are made welcome at any reasonable time. Menus examined were found to be varied and balanced and are evidently based on service users’ identified likes and preferences. An alternative to the main meal is always available. Service users spoken with during the inspection expressed satisfaction with the standard and variety of meals provided: ‘The food here is very good’. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff have developed close and positive relationships with service users and demonstrate an awareness and sound understanding of their individual care and support needs. Service users are protected by clear and comprehensive policies and procedures in place for the control and safe administration of medication. EVIDENCE: The manager emphasised the importance of staff developing close working relationships with individual service users and being aware of any changes in mood or behaviour. Documentary evidence was in place to demonstrate that the health and emotional care needs of service users are continuing to be met within the home. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 16 In accordance with their care plan, service users are fully supported and enabled, as far as practicable, to exercise control over their lives and maintain maximum levels of independence and individuality. During the inspection, staff were observed interacting with service users in a professional and respectful manner. All service users are registered with local GPs and have access to other health care professionals, including district nurses, physiotherapists and dentists, as required. It was evident, in care plans that were examined, that all appointments with, or visits by, health care professionals are appropriately recorded. Up to date, detailed policies and procedures relating to the control, storage, administration and recording of medication are in place. It was noted that since the last inspection, as required, relevant policies and procedures have been reviewed and improved. Medicines are now stored safely and securely and are appropriately recorded. All staff responsible for administering medication have received training and are individually assessed and authorised to do so. This was supported through discussions with staff and evidenced by training records examined The manager confirmed that, following risk assessments, no service user currently self-administers their own medication. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home’s complaints procedure should be reviewed to ensure that service users, staff and visitors feel able to express any concerns, confident that they will be listened to and acted upon. Service users are protected, through policies and procedures relating to abuse and adult protection. However this documentation must also be reviewed and amended to reflect updated guidelines. EVIDENCE: Although there is a simple illustrated complaints procedure that has been developed for the benefit of service users, it does not reflect the current situation within the home or the wider organisation. Following discussion with the management team and in line with many other policies, it should now be reviewed and updated. There is also no adequate or accessible complaints procedure in place for service users’ relatives and other visitors to the home. However it is evident that close working relationships, effective and ongoing communication and consultation and regular service users’ meetings provide opportunity for any concerns to be raised and discussed, before they become complaints. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 18 Service users and members of staff, spoken with during the inspection, confirmed that they would have no hesitation in speaking to the manager or her deputy or making a complaint if necessary and each person was confident that they would be listened to: ‘She (the manager) is probably the best manager I’ve ever had’. She is very approachable and always makes time for you and is always ready to listen’. It was noted that there have been no concerns or complaints recorded by the home since the last inspection. However one complaint, recently received by CSCI, relating to a service user who has since left Kingstone House, is currently being investigated through the organisation’s Head Office. The home has produced detailed policies and procedures, relating to adult protection and abuse, including a whistle blowing policy. However, the area manager confirmed that these documents are shortly to be reviewed and amended in accordance with the recently implemented ‘Multi agency guidelines for the safeguarding of vulnerable adults’. The manager confirmed that all care staff have undertaken appropriate training regarding abuse awareness and adult protection procedures, although she added that this too will be reviewed shortly in light of the new guidelines. This was supported through discussions with members of staff during the inspection and evidenced through individual training records. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The service is safe, accessible, reasonably clean and remains suitable for it’s stated purpose. Service users benefit from generally pleasant accommodation that is comfortable and decorated to a satisfactory standard. However, initial impressions and the overall appearance of the home is affected by the poor standard of the carpets throughout the premises. EVIDENCE: It is evident that, despite previous requirements and recommendations, there has been little change in the physical environment at Kingstone since the previous inspection although standards remain generally satisfactory. The reasonably well-maintained décor and adequate furniture and furnishings continue to provide a comfortable, pleasant and homely environment for service users. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 20 However, of some concern was the poor condition of the carpets throughout the home. One of the first things people see on entering Kingstone House is the staircase leading up from the front door. Unfortunately, at present, the badly stained carpet inevitably creates a very poor and misleading impression of the home and the standards to be expected. The situation did not improve during my ‘guided tour’ of the premises, where it was evident that, despite ‘regular hovering and shampooing’, the stained and badly marked carpets throughout both Kingstone House and Clevelands clearly need to be replaced. The manager confirmed that independence and individuality continue to be promoted within the home and this is evident from the personalising of service users’ rooms, which clearly reflects individual tastes, interests and preferences. It was noted that, as recommended, infection control policies and procedures have been reviewed and improved since the previous inspection. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from there being sufficient trained and competent staff on duty at all times to meet their assessed care and support needs. Service users are protected by satisfactory staff recruitment procedures, training and supervision. EVIDENCE: Care staff at Kingstone House are evidently deployed in sufficient numbers to meet the assessed needs of service users. The manager confirmed that staffing levels within the home are maintained and regularly monitored to ensure that current individual care needs can continue to be met in a consistent manner. All daytime shifts are covered by a minimum of four staff with one waking night and one sleep-in person on duty each night. Adequate staffing levels are also in place in Cleveland’s and The Lodge Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 22 This was further evidenced by the current rota, viewed during the inspection, that details which staff are on duty at any given time and includes their designation. Service users and members of staff, spoken with during the inspection, confirmed that staffing levels within the home are adequate to meet all identified support needs. In addition to the comprehensive induction programme undertaken by all newly appointed staff, the manager confirmed that appropriate core skills training is provided, including first aid, moving and handling, food hygiene and fire safety. This was confirmed through discussions with staff and supported by training records examined: ‘There is always plenty of training here – which is good!’ In accordance with company policy, the manager confirmed that formal supervision is provided for all care staff on a regular basis. This was evidenced by supervision records examined and through discussions with staff, spoken with during the inspection, who acknowledged the benefits of effective supervision and confirmed feeling valued and supported by the manager: ‘Supervision is very useful and the manager is always very supportive’. Through discussions with members of staff, it is evident that the manager also operates an ‘open door’ policy, with staff feeling confident and able to discuss any issues at anytime. The manager is clearly aware of the need for thorough and robust recruitment procedures, to ensure the protection of service users. Individual files that were examined, relating to recently appointed members of staff, were found to be well maintained, containing all relevant and necessary information, including two satisfactory references, proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from competent management. They are protected by satisfactory health and safety policies and procedures, however, their best interests are not always safeguarded by current inadequate and ineffective quality monitoring systems. EVIDENCE: The experienced manager is clearly competent to run the home. She has worked at Kingstone for over three years and has been in her current post since March 2005. Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 24 The manager confirmed that she holds the NVQ level 4, in Health and Social Care and is currently studying for the Registered Manager’s Award (RMA), which she expects to complete early next year. From direct observation and through discussions with service users and members of staff, it is evident that the manager continues to demonstrate a clear sense of leadership and direction. She is clearly motivated, positive and approachable and continues to create an open and inclusive atmosphere within the home. The deputy manager at Kingstone House, since May 2005, also holds the NVQ, level 4 in Health and Social Care. An experienced manager has also been appointed at Clevelands and The Lodge. She has achieved both NVQ level 4 and the RMA. It was noted that the home currently has no effective quality monitoring system in place, however the area manager was able to confirm that a system is currently being developed including satisfaction questionnaires for both service users and their relatives. Positive written comments received recently from a health care professional, indicated a high regard for the home and the quality of service provided: ‘Please pass on my sincere praise for the support and time the staff team have given to ………. in helping reduce her challenges and meeting her needs for structure, routine and being engaged in activities’. The manager confirmed that the health, safety and welfare of service users and staff remain of paramount importance within the home. Staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. All staff training is recorded. COSHH assessments and guidelines are in place. Regular fire drills are undertaken and recorded. Temperature regulators are fitted to all hot water outlets, accessible to service users. All accidents, incidents and injuries are recorded and reported, as required. Kingstone DS0000066070.V355859.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 2 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 x 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 26 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 YA2 Regulation 14 (1) (a) Requirement It is required that, before being admitted to the home, all prospective service users have their care and support needs fully assessed by people competent to do so. It is required that prospective service users know that the home is able to meet their identified individual care needs. It is required that an accessible complaints procedure be developed and implemented, as discussed, for the benefit of service users’ relatives and other visitors to the home. It is required that all parts of the premises, including carpets, be well maintained and kept in a good state of repair. It is required that current quality monitoring systems be reviewed and improved, by seeking the views of service users’ relatives and other stakeholders. Timescale for action 31/12/07 2. YA3 14 (1) (d) 31/12/07 3. YA22 22 (8) 31/12/07 4. YA24 23 (2) 31/01/08 5. YA39 24 (1) (3) 31/01/08 Kingstone DS0000066070.V355859.R01.S.doc Version 5.2 Page 27 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. Refer to Standard YA1 YA2 Good Practice Recommendations It is recommended that the ‘Service User Guide’ be reviewed and amended to reflect the current situation within the home. It is recommended that the current admission procedure, including assessment process, be reviewed to ensure the direct involvement of the registered manager in future admissions to the home. It is recommended that a contents or index be developed and implemented for individual care plans to ensure that information is more readily accessible. 3. YA6 Kingstone DS0000066070.V355859.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 Kingstone DS0000066070.V355859.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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