CARE HOMES FOR OLDER PEOPLE
Kingswood 48 West Street Scarborough North Yorkshire YO11 2QP Lead Inspector
Gill Sample Unannounced Inspection 10:30 18 January 2006
th 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.V271427.R01.S.doc Version 5.0 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.V271427.R01.S.doc Version 5.0 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.V271427.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Registered for 18 Elderly Service Users 5 of whom may also have dementia 17th May 2005 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. The registered provider owns both Kingswood and Continental Lodge which are located almost opposite each other. Mrs. Karen Eyre is the registered manager for the home. Kingswood is built on three floors with a passenger lift serving all floors. The communal space consists of two lounges and a dining room situated on the ground floor. The home has limited outdoor space. There is a garden area with seating at the front of the building. Unrestricted parking is available on West Street. Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report gives the findings of an unannounced inspection which was made on 18th January 2006. The inspection focussed on a number of the key standards and those requirements and recommendations made at the last inspection. Some of the premises were inspected including a number of bedrooms, bathrooms and living areas. A number of written records were also examined. Several users of the service at Kingswood were spoken with and three service users’ records were examined. Discussions were held with the owner and staff on duty while the inspection was being done, a visiting relative and an aromatherapist providing therapy to individual service users. What the service does well: What has improved since the last inspection?
The owners put forward Mrs. Karen Eyre to become registered manager of the home and her application for registration was approved. While Mrs. Eyre was not present at the inspection, service users said that they thought Mrs. Eyre was a good manager and that the staff group seemed to have stability under her leadership. Mrs. Eyre has achieved the qualification for registered managers which meet the standard. The organisation of records relating to service users and staff had improved since the last inspection. Staffing levels have improved, giving staff more time to spend with service users and dedicated time to the recently registered manager to deal with management of the home. Some overseas staff have been appointed since the last inspection and service users commented how they enjoyed being cared for by these staff “they have been a breath of fresh air” “we have wonderful people from abroad”. Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 Page 6 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. Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 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.V271427.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed. EVIDENCE: Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9. Service users are protected by the systems and procedures in place to deal with medication. EVIDENCE: The medication administration procedure was observed. Medication is administered using a monitored dosage system supplied by a qualified pharmacist. Records showed pre-printed medication charts for each service user which were signed in a proper manner and were up to date. The system for dealing with controlled drugs was seen and was satisfactory. There was evidence that medication is stored, administered, recorded and disposed of in a proper manner which ensures that service users are safe. A visiting aromatherapist said that she had been given information on each service users’ medication so that she could ensure that service users had no adverse reaction to therapy. Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed. EVIDENCE: Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Service users are able to make a complaint using information provided by the home. Service users are protected by the awareness of staff of potential abuse. EVIDENCE: Staff spoken with were clear of the course of action they would take if they suspected an abuse. Service users said they would speak to the manager or owner if they had any concerns. A copy of the local authority’s protocol on the protection of vulnerable adults is available at the home. The home’s service user guide has details of the complaints procedure so that service uses can access this information independently. Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed EVIDENCE: Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 29 Staffing levels and skills mix are at a sufficient level to ensure the needs of service users are met. Recruitment and selection procedures are designed to ensure that people who are unsuitable to work with vulnerable adults are not employed, though attention needs to be given to obtaining new criminal records disclosures on all staff prior to appointment. EVIDENCE: Of the twelve staff employed at the home, one has NVQ 3 and one an NVQ 2 in care. A further member of staff is registered to start NVQ 3 in care and another is currently doing NVQ level 2. Individual staff files showed that staff had undertaken mandatory training in health and safety topics, but there was no document available to show the overall training needs of staff as a group. The manager spends some of her time working alongside other staff on duty providing care to residents. Four weekly staff rotas were supplied at the inspection and were analysed. Based on 14 service users at the home, two of whom have dementia, the required minimum day staffing levels required are 306 hours per week. A requirement was made at the last inspection that the registered provider ensures that minimum day staffing levels were monitored to ensure that service users were not put at risk. Four rotas analysed in detail showed that the minimum staffing levels required were exceeded by 28 to 45 hours per week. Analysis of the rotas supplied at inspection showed that a minimum of three staff are on duty during the day and evening, with two staff on duty each night. Significant improvement in the day staffing hours
Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 Page 14 available to service users has been made. Eight hours per week are built into the rota for the registered manager to deal with administration matters. Three staff records were seen of care staff on duty at the inspection. These showed that proper checks had been carried out. For overseas staff employed by the home via an agency, police checks from their country of origin had been obtained. One record showed that a criminal records disclosure dated 2002 had been supplied by the applicant in relation to previous employment and no new disclosure had been applied for by the registered owner or manager. Criminal records disclosures are not transferable from service to service. Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 Page 15 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 38 People living at the home can be assured that their health and safety is being addressed though the homes fire containment measures need to be addressed. EVIDENCE: The manager Karen Eyre has become registered under the Care Standards Act in respect of the home. She completed the NVQ level 4 in care and management since the last inspection. The registered provider Mr. Devine continues to spend time at the home on a daily basis and demonstrated a knowledge of service users as people and an awareness of their needs. A number of documents were seen relating to the home’s responsibilities under health and safety legislation. These were: • Servicing document for passenger lift dated 2/12/05
DS0000007653.V271427.R01.S.doc Version 5.0 Page 16 Kingswood • Electrical equipment tests dated 23/10/04 • Electrical installation safety certification dated 23/10/04 (valid for five years) • Environmental Health Department visit dated 6/10/04 • Insurance certificate for public and employers’ liability dated valid until 28/9/06 • Risk assessment documentation covering activities and use of equipment The Gas Safety Certificate could not be located by the registered provider who agreed to send a copy of the document to the Commission. While there were documents and records detailing the arrangements to ensure proper fire precautions and safety procedures are in place, these are not detailed in a fire risk assessment which would enable risks to be assessed and minimised. The registered provider undertook to obtain a copy of the document. Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 1 Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 OP29 Regulation 19 Schedule 2 Requirement Timescale for action 31/01/06 2 OP38 23 Confirmation of a criminal records disclosure at an enhanced level must be obtained on all staff to ensure that they are suitable to work with vulnerable people. Fire doors must not be wedged 18/01/06 open. An alternative means must be found to hold the door open which does not compromise the homes fire containment measures. Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 Page 19 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 OP28 Good Practice Recommendations OP3850 of care staff should obtain a National Vocational Qualification at Level 2 or above by 2005. An overall training record should be developed for all staff to enable the manager to identify training needs. A fire risk assessment document should be obtained and completed. 2 OP38 Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kingswood DS0000007653.V271427.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
