Inspection on 10/11/05 for Kingswood Court

This inspection was carried out on 10th November 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kingswood Court 04/02/08

Kingswood Court 10/09/07

Kingswood Court 23/05/07

Kingswood Court 04/05/06

Kingswood Court 31/05/05

Kingswood Court 24/02/05

Kingswood Court 14/12/04

Kingswood Court 21/06/04

Kingswood Court 24/05/04

Kingswood Court 15/02/04

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Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Kingswood Court Soundwell Road Kingswood South Glos BS15 1PN Lead Inspector Melanie Edwards Unannounced Inspection 10th November 2005 09:45 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 Court DS0000020249.V263238.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 Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kingswood Court Address Soundwell Road Kingswood South Glos BS15 1PN 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) 0117 9603722 0117 9603744 Grandcross Limited(wholly owned subsidiary of Four Seasons Health Care Ltd) Mr Aubrey Sibiya Care Home 66 Category(ies) of Old age, not falling within any other category registration, with number (66) of places Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. May accommodate up to 66 persons aged 50 years and over who are receiving nursing care. Of the total 66 persons, up to 3 persons (who must be 65 years or over) may be accommodated and provided with personal care only. Manager must be a RN on parts 1 or 12 of the NMC register Staffing notice dated 22/6/1998 applies. May accommodate one person under the age of 50, who has physical disability. This condition relates to a named person and will lapse if the person leaves the home. 31st May 2005 Date of last inspection Brief Description of the Service: Kingswood Court is a purpose built home, operated by Grand cross Ltd, which is affiliated to Four Seasons Health Care. The home is registered to provide nursing care for 66 people over the age of 50. It has ample car parking space at the rear and a small garden in front separating it from the main road. There is access to local shops, amenities and bus routes. Accommodation is provided over three floors; each floor has its own lounge and dining area. There is level access throughout the home and a lift to each floor. Toilets and bathroom facilities are adequate for the number of service users and have adaptations to meet their assessed needs. All rooms are equipped with call alarm systems. Visitors may visit at any time. An activities organiser is employed and organises a varied programme of activities throughout the week. Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Sixteen residents and a number of relatives and visitors were consulted to find out their views of the Home. The manager, one registered nurse, a number of care assistants, and the cook were also consulted about roles and responsibilities, training needs, and how they support residents. A selection of records relating to running and management of the Home were inspected. A range of resident’s records and care plans were also inspected. The majority of the environment was inspected and the only areas not viewed were a small number of resident’s bedrooms. What the service does well: What has improved since the last inspection? What they could do better: The health and safety of residents’ and staff would be better maintained if the kitchen fridge were replaced, as there is an area of rust around the bottom seal, and this may mean the fridge ceases to work effectively. Residents would benefit if all care plans were written clearly and demonstrated how needs are met. It would also be beneficial if assessment records include information about the type of skin pressure relieving equipment residents are provided with. The signing and dating by staff of `bed rails’ risk assessments better protects residents, by demonstrating when the need for bedside rails has been assessed, and when it must be reviewed. The dignity of residents during meal times would be enhanced if all staff assisting residents with meals sit down next to them. One member of staff was observed standing up next to residents while helping them. Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 6 The overall quality of care and delivery of service provided would be further improved if at least fifty percent of care staff complete a National Vocational Qualification in care award by the end of 2005. 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 Court DS0000020249.V263238.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 Court DS0000020249.V263238.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): 1,3,4, Residents and their representatives are provided with the necessary information to help them make an informed choice about the Home. Residents’ assessed needs are met. EVIDENCE: Copies of the statement of purpose and service users guide were inspected to see what information the Home provides for prospective residents and representatives. Both documents contained information about life in the Home, the staffing structures and levels that are in place, as well as the service that is provided. There are also colour pictures of inside and outside of the Home included in the service users guide, which is a helpful form of additional information. Copies of the service users guide are on display in the entrance hall, which is a well-frequented area. Six residents assessment records were inspected to find out how residents needs are assessed. The records were generally informative, and showed what residents physical, mental and social needs were. The assessments also demonstrated how each person’s needs are to be met. Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 9 However for residents who require skin pressure-relieving equipment there was no written information in assessment records indicating what equipment was in use. This information is required to demonstrate an accurate assessment of residents needs. A range of comments were made by residents about the care they are provided with examples of comments made by residents included, `the main staff are marvellous’, `I’m quite happy I get on very well with all the girls’, the home is very good the carers are excellent’, `it’s alright here’, and `the staff seem to be working pretty hard.’ Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, Generally care plans demonstrate nursing and personal care needs are being met. EVIDENCE: Six care plans were inspected to find out how residents are supported to meet their needs. The care plans were reasonably informative and detailed how to meet the health care needs of the person. However one resident’s care plan was vague in detail and did not clearly state what actions staff must follow to assist the resident to meet their needs. The care plan also included some information that was inaccurate as it failed to demonstrate how to maintain the residents safety and it had also been written in a subjective and negative style . Care plans had been reviewed and updated regularly by registered nurses, demonstrating residents’ health needs are monitored and reviewed. Included with care plans were assessments for each resident of their nutritional needs and skin pressure vulnerability. Registered nurses are reviewing assessments on a monthly basis. This helps to demonstrate staff are monitoring residents assessed needs. Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 11 There were risk assessments for residents who require bedside rails. One of the assessments had not been signed or dated, making it hard to check who carried out the assessment and when they did it. There was also a record seen for each resident of when they had seen the GP. The records showed visiting GPs are seeing residents on a regular basis to attend to their health care needs. Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 Residents are provided with a range of social and therapeutic activities, and are offered an adequate, well-balanced diet. EVIDENCE: An activities organiser works five days a week and undertakes a range of activities with residents. A number of residents said they enjoyed the range of games and quizzes that take place. Residents also said there are outings to areas of local interest in warmer weather. There are regular musical afternoons held with different entertainers. During the inspection a pianist played `old time songs’ and a number of residents attended this event and looked as if they were enjoying themselves. There is also an `activities’ timetable circulated to every resident each month, so that they are aware of what is going to be happening. A number of residents said they felt meal choices were good, and they liked the food that is provided. Several residents also said they thought the food menu `bland’, `repetitive’ and there was not enough fresh fruit or vegetables. The residents menu was inspected to find out what type of food is provided. The choices seen were nutritionally well balanced and reasonably varied. The inspector took the opportunity to sample lunch. The meal consisted of either fishcakes or lamb chops with boiled potatoes, and vegetables, followed by a choice of dessert. The fishcake was sampled and tasted adequate. Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 13 Staff were observed assisting residents with lunch, the majority of staff assisted residents in a relaxed and respectful manner. One member of staff was observed helping residents by standing up next to them while assisting them with their meal. It is better practice, and more dignified for residents when assisting them with meals, to sit down next to them. Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 14 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): 16,18 The manager is responding effectively to complaints , and there are systems in place to help protect residents from abuse. EVIDENCE: There is a copy of the complaints procedure included in the service users guide, and a copy of is given to residents on admission. There is also a copy of the procedure on display, which means visitors can obtain this information if wishing to complain. The Commission for Social Care Inspection has not investigated a complaint since before the last inspection. There was evidence that Mr Sibiya had responded to four complaints he had received, promptly and thoroughly. Many residents and several relatives said they felt able to speak to Mr Sibiya if they had any concerns. One comment that reflected the tone of residents views, was `Aubrey listens and then he sorts it out’, referring to Mr Sibiya’s response to complaints. The Home has a `Protection of vulnerable adults from abuse’ procedure as well as guidance information including a copy of the ‘No secrets’ government issued document for the protection of vulnerable adults from abuse. This information should help protect vulnerable adults who live at the Home by increasing staff understanding of what actions must be taken in the event of an allegation of abuse. A number of staff have attended training to help them better understand issues on the topic of the protection of vulnerable adults from abuse. Staff attending such training is beneficial as it increases their awareness of the needs and rights of vulnerable adults in their care. Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 The Home looks safe and satisfactorily maintained and is suitable for the needs of residents. EVIDENCE: The Home is located close to private houses, and a short distance from local shops and nearby bus stops, making the Home very much a part of the local community. The building is wheelchair accessible; and there is a passenger lift for access to the first and second floor. The Home is a purpose built nursing home, designed around the needs for which it is intended. There are adaptations in place throughout the Home to assist residents as well as visitors who are disabled. The majority of the building was viewed both inside and out. The only areas not seen were a small number of bedrooms The environment was maintained to a satisfactory standard, and the standard of the fixtures and fittings was satisfactory. Residents were observed sitting in all of the communal areas and bedrooms, they looked relaxed and comfortable. Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 16 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): Residents are supported with their needs by competent staff who are provided with training to enable them to carry out their roles. EVIDENCE: Staff were observed carrying out their duties and assisting residents in a calm and friendly manner. In discussion with staff on duty, they demonstrated a good understanding and awareness of the needs of residents in their care. Residents commented generally positively about the attitude of staff who help them. Examples of comments made by residents included, `the staff are very good they are excellent ’, `some are more helpful then others’, and `the staff are very good’. The training records of two registered nurses and three care assistants were inspected to see if registered nurses were keeping up to date with their clinical knowledge and practice and what training care staff are provided with. There was evidence that showed registered nurses and care assistants had attended some clinical and other relevant training and updating in the last twelve months. However the Home is significantly behind in meeting the targets set by the National Minimum Standards of fifty percent of care staff achieving an National Vocational Qualification in care award by the end of 2005.The manager said that there has been some recent progress in putting in place a National Vocational Qualification training programme. The Commission for Social Care Inspection will follow up progress at the next inspection. Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The manager is trying to run the Home in a way that is in residents’ best interests, and generally the health and safety of residents and staff is maintained. EVIDENCE: A number of residents were asked if they saw Mr Sibiya regularly. While many residents said Mr Sibiya was often busy they also said he was kind and would gladly make time to see them if they needed to speak to him. Residents also said that Mr Sibiya regularly asks them their views of the Home. Two residents said Mr Sibiya had recently invited them to his office for a drink and an informal `chat’ to find out their views of the Home. There is a resident and relatives meeting planned for early December, and posters were on display inviting residents and relatives to attend and give their views. Mr Sibiya has carried out a quality audit of residents care plans, following a recent audit of care carried out by advisers from the company who run the Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 18 Home. This demonstrates a commitment to monitoring and improving quality of care. The fire logbook was checked and showed weekly tests of fire alarms being carried out. The fire fighting equipment was also being checked regularly, thereby helping to maintain the safety of those in the building. There was a record that showed staff attended fire safety training in the last twelve months, to ensure they were aware of fire safety procedures. The kitchen was tidy and organised when viewed, however one of the kitchen fridges has an area of rust along the bottom seal, and needs to be replaced as this is a health and safety risk. The records of cooked food temperatures and kitchen fridge and freezer temperatures for the previous two weeks were seen these records were up to date helping demonstrate catering staff follow safe food storage and cooking practices. Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 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 3 X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 X 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X X 3 3 3 Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 20 Yes 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 OP7 Regulation 15.(1) Requirement Residents care plans must be objective and clearly state what actions must be taken to support the person to meet their needs. The kitchen fridge identified at the inspection must be replaced. Residents bedrails risk assessments must be signed and dated by the person completing the assessment. Timescale for action 10/12/05 2 3 OP38 OP7 16.(2)(g) 13.(8) 10/01/06 11/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP28 OP3 Good Practice Recommendations A minimum of 50 of care staff should have obtained National Vocational Qualification in care award by 2005 Where applicable, residents assessment information should include the type of skin pressure relieving equipment that is provided. Kingswood Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Court DS0000020249.V263238.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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