Inspection on 10/05/07 for Kingswood

This inspection was carried out on 10th May 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

Kingswood 08/05/08

Kingswood 31/08/06

Kingswood 18/01/06

Kingswood 17/05/05

Kingswood 30/09/04

Kingswood 28/04/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Kingswood 48 West Street Scarborough North Yorkshire YO11 2QP Lead Inspector Gill Sample Key Unannounced Inspection 10th May 2007 09:50 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 Kingswood DS0000007653.V335102.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. Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingswood Address 48 West Street Scarborough North Yorkshire YO11 2QP 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) 01723 363263 Mr Robert Leonard Devine Mrs Brenda Devine Mrs Karen Eyre Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 18 Elderly Service Users 5 of whom may also have dementia 31st August 2006 Date of last inspection Brief Description of the Service: Kingswood provides personal care and accommodation for a maximum of eighteen older people up to five of whom may also have been assessed as having a significant dementia. The home does not provide nursing care. The home is located in the South Cliff area of Scarborough and is conveniently situated for all of the main community facilities and the public transport network. Mrs. Karen Eyre is the registered manager for the home. Information is given to new and existing service users to the home detailing the accommodation, facilities and services provided. The weekly fee was quoted by the provider as being between £350.00 and £375.00 per week in April 2007. Charges not included in the weekly fee are made for private chiropody of £10, aromatherapy of between £10 and £15, and varying costs for hairdressing. Kingswood is built on three floors with a passenger lift serving all floors with bath and toilet facilities on each floor. The communal space consists of two lounges and a dining room situated on the ground floor. There is a garden area with seating at the front of the building. Unrestricted parking is available on West Street. Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report gives the findings of a key inspection including visits to the service which were made on 10th and 23rd May 2007. The first visit focussed on the key standards and those requirements and recommendations made at the last inspection and the second visit to look at staffing records. A total of six hours were spent at the home. There were sixteen residents living at the home. Prior to the visits, the registered manager Mrs. Karen Eyre had provided information about the service. Recent events and contact between the home and the Commission was analysed using records held at the Commission’s York office. At the first visit, the premises were seen including some bedrooms, bathrooms, living areas, the kitchen and laundry. A range of written records and documents were also examined and practice was observed during the visit. The second visit focussed on looking at staffing records. Individual discussions with people living at the home, their visitors, the deputy manager Lesley Bayes and staff on duty at the time formed part of the key inspection. Six written comment cards were sent to people living at the home before the visit, five of which were returned. Written comments were also requested from the relatives of three people living at the home, two of which were returned. What the service does well: What has improved since the last inspection? The registered manager has progressed requirements made at the last inspection of the service. These were to ensure that proper checks of criminal records are made prior to appointing new staff, making sure the home’s gas installation was certified and developing a system to check quality standards at the home. Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 6 The home has been redecorated in some areas. There is now a system in place to record the maintenance needed in the building. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 7 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 Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply. People who use the service experience good quality outcomes in this area. They can be assured that their needs will be properly assessed and recorded before entering the home and make an informed choice about going to live there. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Case records seen showed that proper assessment had been made of people’s needs prior to them coming into the home. These covered aspects of people’s physical, social and health care needs and background information on each person. One person had come to live at Kingswood following transfer from another care home. A new assessment had been made of this person’s needs by the registered manager rather than rely solely on the information provided by the former care home. The preferences of people had been recorded so that staff could provide care in a way which suited individual people. For instance, it was recorded that a person did not like to have their hair washed while in the bath. Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience adequate quality outcomes in this area. They can be assured that their health and personal care needs will be identified and will be given in a way which they prefer. However, practice needs to improve so that the privacy and dignity of people with dementia is respected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: All care planning records seen showed detailed individual information so that care staff had access to information to be able to provide good care. Monthly reviews of the care needs of individual people were seen including health issues which had been recognised and addressed. Records showed that medical attention and advice had been sought by the manager and staff in these circumstances. One person had wished to cease taking medication and records showed that medical advice had been sought so that the person could make an informed choice about this. Individual preferences about the way personal care is provided were recorded. Where people had agreed to share a room, a written agreement about this was recorded and kept on their files. Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 10 Working patterns were discussed with staff and following the visit with the registered manager. It became clear that some people living at the home were being changed into nightclothes at teatime. This potentially identifies those with incontinence. Practice needs to improve in this area to ensure that the privacy and dignity of people, particularly those with dementia, is respected and that staff work in the best interests of residents. This was discussed with the registered manager following the visit. The system for administration of medication was seen. The system is a monitored dosage system supplied by a pharmacist in which ongoing medication records are pre printed and any short course medication, such as antibiotics, is added to the record sheets by hand. Information supplied prior to the visit said that nine staff had undertaken a course on the safe handling of medicines. The recording of medication given was up to date. Storage of medication was secure. Written comments received from people living at the home said that staff are available to them and that they always received the medical support they needed. One commented, “All the staff are kind and look after me very well.” A relative commented “They (also) keep us fully informed of Mum’s needs. It’s very much a two way operation.” Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. Daily life and social activities offer service users opportunities to live their preferred lifestyle and retain relationships in the wider community. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home has a mixture of people, some of whom can make all decisions about their lives and others who have a degree of confusion. Staff were seen talking with residents and spending time with them. There were no organised activities during the visit to the home. People were singing to music in one of the two sitting rooms. However, a visiting hairdresser was at the home doing two female resident’s hair. Written comments from people living at the home detailed some individual trips outside the home with staff and one person said that they kept weekly contact with their family over the telephone and went every week to their family for the day. A musical entertainer was due to come to the home the day after the visit. One person said “If I want a walk out, one of these ladies (staff) will go with me.” People also said that they had been taken out for a morning drive the previous day by Mr. Devine, the owner of the home. Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 12 A visitor was seen who said she was very satisfied with the service that the home provides. She said that she and other members of her family were always made welcome. Lunch was seen being prepared and served in the dining room, which can seat twelve people at one time. One person was served their meal in the sitting room and one has their main meal in the evening. Lunch was presented in an appetising way and included fresh produce. Home baked cakes were seen which had been prepared for tea. Observation in the dining room showed that people were not rushed, received the attention they needed from staff, and the dining room had a relaxed atmosphere. The home’s dining room can seat twelve people at one time. This means that when the home is full, not everyone can eat together at the same time. Information supplied prior to the inspection showed a variety of foods are included in the planned menus. Evidence was seen that personal food dislikes are recognised and recorded. For example, one person said that they did not like rice pudding and this was seen noted on their records. A written comment from a relative said “Mum is eating more and better than ever she has.” Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. They are able to make a complaint using information provided by the home and are protected by the awareness of staff of potential abuse. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A complaints procedure is in place and people living at the home are given information on how to make a complaint. People said that they would speak to the manager or owner of the home if they wanted to make a complaint. Information on how to make a complaint was seen posted in the hallway so that people who live at the home, their relatives or any other visitor has access on the procedure. Written comments from people living at the home said that they knew who to speak to if they were not happy with their service. One written comment received from a relative said they had not had information given to them about how to complain and had not had the complaints procedure explained to them. There are policies on the protection of vulnerable adults and a whistle blowing policy so that staff can disclose poor practice without fear for their own position. Care staff spoken with said that they were aware of potential abuse and had done training on the recognition of potential abuse. They said they would report any suspected abuse to the manager or senior staff, so that people who live at the home would be safeguarded. Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. The home provides a clean and comfortable place in which to live. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: All the general areas of the home, some bedrooms and bathrooms, the kitchen and laundry were seen. Areas of maintenance outside the building identified at the last visit had been addressed. The home was clean and there was no unpleasant smell. There have been improvements in the standard of decoration since the last visit and some bedrooms have been redecorated in keeping with the style of the building. A record of maintenance, replacement and redecoration was seen. People who live at the home are provided with comfortable seating in two sitting areas so that they can choose where and with whom they spend time. Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good outcomes in this area. People are cared for by a competent staff team, though improvements can be made in the home’s recruitment process. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Staffing records were not available for inspection at the visit to the service and a second visit was made to examine these records. These records should be made available for inspection so that checks can be made by inspection to ensure people who live in the home are safeguarded. Records of four staff were seen, two of which were in the process of recruitment. Records showed that written application, two references and a criminal records check were necessary prior to staff starting work at the home. One record showed that offences had been disclosed and discussion with the applicant had taken place about this, but no recording had been made of the discussion nor the judgement of the manager about whether to appoint the person or not. Staff receive formal appraisal but not formal supervision. Care staff and records showed that appraisals were carried out twice a year. The assistant manager on duty said that she had undertaken training on the supervision of staff. Information supplied before the visit showed that of the fourteen care staff, seven had obtained an NVQ qualification. The target of fifty per cent of care staff achieving qualification to NVQ Level 2 in care is currently met. Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 16 A staff training programme of mandatory health and safety topics and subjects pertinent to the care of people living at the home is provided on a rolling programme so that staff are properly trained for the work they undertake at the home. Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience adequate quality outcomes in this area. They can be assured that the service is managed by a competent person supported by the provider, though the development of a formal quality assurance system would assist the manager to identify areas of service which can be improved. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A range of documents and records were seen covering the arrangements to ensure that the home complies with health and safety legislation and is a safe place in which to live and work. Following the last inspection, the owner was required to obtain a certificate confirming the home’s gas safety. The following were seen: ● Gas Safety Certificate dated 28/09/06 DS0000007653.V335102.R01.S.doc Version 5.2 Page 18 Kingswood ● ● Records of tests on fire alarms, emergency lighting and fire detection systems Environmental Health Officer’s report which made recommendations which the service is addressing A hot water temperature check was made in a bathroom. This was slightly cool and was discussed with care staff on duty, who said that people had not complained about the water temperature. Staff training records showed that staff receive health and safety training on a rolling programme so that they can provide care in a safe manner. Care staff were able to detail the training they had completed. There is no formal system to ensure that the quality of service is being monitored. The manager said that the views of people living at the home are taken into account in the day to day running of the home, but there is no strategic method of identifying where improvements can be made nor in implementing improvement. A system needs to be developed which is based on the views of residents, their relatives or representatives so that the service can be improved in the best interests of people living at the home. This was discussed with Lesley Bayes at the visits to the service and advice was given. Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 19 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 3 Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 20 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 OP10 Regulation 12(4)(a) Requirement Care practice at the home must ensure that people are treated with dignity and respect. Staff records must be available for inspection at all times. There must be a quality monitoring system in place based on the views of people living at the home and others in measuring and improving the quality of care provided by the home. Timescale for action 30/06/07 2 3 OP29 OP33 17(3)(b) 24 30/06/07 31/07/07 Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations The registered provider should keep under review the dining arrangements and dining space to best meet service users’ assessed needs. Where offences have been disclosed during the recruitment of staff, discussion with the applicant and the judgment of the registered manager should be recorded, including any additional safeguards which are put into place, e.g. additional supervision or an extended probationary period. Staff should receive formal supervision so that their practice can be monitored and they are given opportunities to develop. 3 OP38 Hot water outlets need to be checked so that they are delivered at a safe and comfortable temperature. 2. OP29 Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Kingswood DS0000007653.V335102.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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