Inspection on 10/09/07 for Kingswood Court

This inspection was carried out on 10th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 23/05/07

Kingswood Court 04/05/06

Kingswood Court 10/11/05

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

Similar services:

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 and 12th September 2007 09:30 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.V346286.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 Court DS0000020249.V346286.R01.S.doc Version 5.2 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 kingswood.court@fshc.co.uk 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.V346286.R01.S.doc Version 5.2 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. 23rd May 2007 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 residents and have adaptations to meet their assessed needs. All rooms are equipped with call alarm systems. Visitors may visit at any time. The fees charged for staying at the Home for care range from £359 to £471 per week. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection lasted eleven and a half hours and was carried out over two days. The inspector met twenty-one of the fifty-eight residents living at the Home. A number of visitors were also consulted. The manager, one registered nurse and three care assistants were consulted about their roles and responsibilities, their training needs, and how they assist and support residents. Residents were observed being assisted with their needs by staff. A selection of records relating to the day-to-day running and management of the Home were inspected. A range of resident’s care records and care plans were also reviewed. Five regulation 37 reports, (this regulation refers to the requirement for Homes must report to us about serious incidents effecting residents), and the action taken by the Home were reviewed. The majority of the environment was seen. The only areas that were not viewed were a small number of resident’s bedrooms. A number of survey forms were returned to the Commission from residents and relatives. The information in these is used in the report. Sue Fuller, the Commission Pharmacist Inspector for the Bristol area, carried out an inspection of medication standards in the Home. An additional more detailed letter has also been sent to the acting manager at the home. The Home was operating within the required conditions of registration set down by The Commission. The conditions of registration set out the type of care and the needs of residents as well as the numbers of residents who may stay at the Home. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Mrs. Linda D’eath has been appointed as a temporary manager while Mr Aubrey Sibiya is absent from the Home. Oxygen cylinders have been secured so that they cannot fall over and appropriate warning signs have been attached to the doors of storage areas. Records for the administration of creams and ointments have been improved, showing that these are being applied as prescribed. Additional sheets giving guidance for the administration of some medicines prescribed, When required have been completed to help ensure that these medicines are given appropriately. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 7 What they could do better: The Home must be able to demonstrate it can meet residents’ needs. Examples of needs not being met include, residents with vulnerable skin not consistently being given the care they need. This was demonstrated by `turn chart’ records that showed residents not being assisted as often as they need to be. This was further evidenced by care plans that were not being fully followed. Specifically certain resident’s dressings were not being changed as often as the care plans said they should be. Another example of needs not being met included a lack of information in fluid balance records (these records show how much fluid someone drinks and how much urine they pass). The lack of information suggests residents are not always offered enough regular fluids during the day. The staff are also not monitoring if residents are passing enough urine to stay in their optimum health. Registered nurses must keep accurate records of the nursing care provided to residents. Specifically the times that staff had helped to move one resident had been filled in retrospectively .The times that had been put were not accurate. It is a requirement of the Registration body that register Nurses (the Nursing and Midwifery Council) that registered nurses follow a code of conduct for record keeping. It also a failing in the Home as this means records are not reliable. Call bells in bedrooms (used by residents to ring for assistance) must be available and in easy reach of residents. Specifically five residents had call bells that they could not reach. There were two bedrooms that did not have call bells in them. All staff directly involved in caring for residents should attend training in understanding the principal of the protection of vulnerable adults so that residents are safe and protected. Residents who are in wheelchairs should not be `lined up’ in a row by the lift when the staff are helping residents to go downstairs. This practise is impersonal. One of the emergency lights on the top floor must be repaired as currently it is flickering on and off. This means it will not work properly in an emergency. Male residents who may need a protective apron when eating their meals should be provided with an apron that is suitable for them. This is in relation to a male resident being given an apron to wear that was floral patterned. Some out of date injections need to be disposed of safely to make sure that they cannot be used in error. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 8 Disposal of Controlled Drugs must be recorded in the appropriate register to make sure that these medicines have been disposed of safely. Records must be kept of medicines, which have been returned to residents who leave the home. This is to make sure that there is a clear audit trail for all medicines received into the home. Action is needed to make sure that the correct devices are available for blood testing. This is to avoid the risk of blood-transmitted infections. 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 Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 9 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.V346286.R01.S.doc Version 5.2 Page 10 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): 1,3. Quality in this outcome area is adequate. Residents’ needs are assessed. Residents and their representatives are provided with information to make an informed choice about living at the Home. Residents are not are provided with intermediate care at the Home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: To find out how prospective residents and their representatives are helped to find out about the Home a copy of the service users guide was read. The statement of purpose could not be located by the new manager .The inspector did see a copy of the statement of purpose in May 2007, at the last key inspection. This will be reviewed at the next inspection. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 11 Each resident is given their own copy of the service users guide so they can find out about life in the Home. The guide includes information about the service provided, the qualifications of the staff employed, and the accommodation. The philosophy of the Home and how the service aims to meet residents’ needs is included. The complaints procedure is in the document so residents know how to complain. To find out how staff plan residents care, six assessment records were looked at in depth. There was a nutritional needs assessment for each resident to show what the residents dietary and nutritional needs are. There was also a skin vulnerability assessment completed for residents. The assessments show that the residents’ risk of developing pressure sores has been assessed. There are risk assessments in place to support residents to be able to maintain their own safety in the Home. There are risk assessments for residents who require bedside rails. The assessments had been signed and dated, to show who carried out the assessment and when they did it. The benefit of these risk assessments is that they should help staff to support residents in their daily lives. The staff on duty were assisting residents with their needs in a friendly way. A number of care staff were talking with residents in a warm and kind manner. A number of residents expressed a range of views about the care and service they received. Examples of comments made by them included, ‘ as far as I can see I am well looked after ’, ` the staff don’t come promptly when I call the bell ’, `the staff are very good’, ‘I haven’t really got any complaints about the place ’, and `the staff at the Home are ok but the agency helpers don’t know what to do’. There are no residents living at the Home solely for intermediate care. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 12 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): 7,8,9,10. Quality in this outcome area is poor. Residents’ care plans do not all satisfactorily demonstrate how needs are met. Residents’ needs are not always being met, and care plans are not always followed by staff. Residents are not always being treated in a manner that is respectful and dignified. Safe procedures are in place for administration of medicines, however some improvements are needed in the handling of medicines to further safeguard residents’ health. This judgement has been made using available evidence including a visit to this service. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 13 EVIDENCE: Six care plans were read to find out how staff help residents to meet their needs. The care plans seen set out how to meet some of the needs of the residents. Care plans included information for staff to follow to support residents with physical, psychological and communication needs. Care plans had been reviewed and updated regularly by registered nurses. This helps demonstrate residents’ needs are reviewed. There were assessments included with care plans of each resident’s nutritional needs, their skin pressure vulnerability and their risk person falling. Registered nurses are reviewing assessments on a reasonably regular basis. This helps to demonstrate staff monitor residents’ assessed needs. The inspector monitored the care of two residents who have very vulnerable skin. There was a lack of information in the `turn chart’ records (used to record how often staff help to move the person and relieve the pressure on their skin). This suggests residents are not helped as often as they should be. This was further evidenced by care plans that were not being fully followed. Specifically certain resident’s dressings were not being changed as often as the care plans said they must be. There was also a lack of information in fluid balance records. The lack of information suggest residents are not always offered enough regular fluids during the day .The staff are also not monitoring if residents are passing enough urine to stay in their optimum health. One resident who needed to be moved in bed at least every four hours, had not been moved for over six hours according to the record of when staff had assisted them. This omission could lead to the residents skin breaking down if it were repeated. When this was bought to the attention of the manager, she addressed the situation immediately. However the inspector later returned to check the residents `turn chart’ record. The record had been filled in retrospectively. The record said the resident had been assisted to be moved at a time when the inspector was with the resident and they had not been yet been moved. This inaccurate record keeping must be dealt with satisfactorily as a matter of priority. The content of all the care plans continues to fail to reflect residents’ unique cultural and diverse needs. This was particularly noticeable for one resident. Their care plan continues to fail to reflect properly their culture, and the impact this may have on their needs. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 14 There were call bells in bedrooms that were not easily available and were out of reach of the residents who require them. Specifically five residents had call bells that they could not reach. There were also two occupied bedrooms that did not have call bells in them. This has a direct, and negative impact on residents needs being met. There was information in the care records that showed when residents see a Doctor. The records showed GPs. see residents on a regular basis to attend to their health. One GP visited the Home for appointments with residents during the inspection. A physiotherapist also visits residents when required to carry out assessments of their mobility. This helps to demonstrate that outside professionals support residents with health needs. Staff were observed knocking on doors before entering the rooms, and communicating with residents in a friendly manner. However, a number of residents in wheelchairs were seen being `lined up’ by staff to wait in a row by the lift. This was when waiting for staff to help them go downstairs. This practise is impersonal and suggests residents are not treated as individuals. A male resident who needs a protective apron when eating their meals was provided with an apron that was floral in design. Staff had given the apron to them. Staff said that they administer all medication because none of the residents are currently able to look after their own medicines. I saw the lunchtime medicines being given on one floor. These were given safely and the medicines administration record sheet was checked and signed as the medicines were administered. Safe storage is available for medicines. Some out of date injections were seen in one medicine fridge and these must be disposed of safely to make sure that they cannot be given in error. Oxygen cylinders have been secured so that they cannot fall over and appropriate warning signs have been attached to the doors of storage areas. Suitable storage is provided for medicines which need to have extra security. Some records in the Controlled Drugs register were not accurate. Clear records must be kept in the Controlled Drugs register of the disposal of these medicines. This is to make sure that they have been disposed of safely. Medicines administration record sheets and a check of the blister packs of medicines indicated that medicines have been administered as prescribed by the doctor. Records for the administration of creams and ointments have improved, showing that these are being applied as prescribed. Some improvements are needed in recording to make sure that medicines supplied in standard packs can also be audited to make sure that they have been given correctly. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 15 Additional sheets giving guidance for the administration of some medicines prescribed, When required have been completed to help ensure that these medicines are given appropriately. Records are kept of the receipt of medicines into the home and of the disposal of medicines. However no records are kept of any medicines that are returned to residents who move from the home to alternative care. Action must be taken to make sure that records are kept of all medicines removed from the home. This is to make sure that there is a clear audit trail for medicines and that all medicines have been disposed of safely. There was some discussion with staff about the use of appropriate blood testing devices, which have been the subject of MRHA warnings. Action is needed to make sure that the correct devices are available for safe use, to avoid risk of blood-transmitted infections. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 16 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): 12,15.Quality in this outcome area is adequate. Residents are provided with a generaly satisfactorily nutritious diet, and can take part in social and theraputic activities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents said they take part in different social and therapeutic activities with the support of the activities coordinator who works four days a week. In the afternoon a small number of residents went for walks in the garden with the activities organiser and care staff. This means residents can sit outside on a sunny day. Although the care staff were busy, they were seen spending some time when they could talking with residents about social matters. This is clearly valued by residents and its importance should not be underestimated. There was information seen about some of the social activities being planned in the Home. A group of residents were watching an old film on video during the afternoon .The residents concerned looked as if they were enjoying this activity. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 17 A hairdresser service is available during the week and a number of residents were having their hair attended to. They looked as if they were enjoying this activity. The menu was reviewed to see what range of meals choices residents are offered. The Home operates a four-week flexible menu. The menu choices were varied and there was range of traditional meals provided. The lunchtime meal was observed being served on two floors of the Home. The meal choices consisted of either baked salmon, or corned beef hash, and cooked vegetables and potatoes. The meals were adequately tasty. Care staff were working hard serving food to residents in their rooms, and in the dining rooms. Residents needing extra help with their meals were being helped in a discrete way by staff who sat down next to them. This practise helps maintain the person’s dignity and make the mealtime more personal for residents. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 18 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): 16,18. Quality in this outcome area is adequate. Residents’ and their representative complaints will be taken seriously and acted upon. Residents would be better protected if all staff involved in caring for residents attended up to date training on the protection of vulnerable adults from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a copy of the complaints procedure on display in the reception area, and on each floor. This includes the contact information for the area office of the Commission for Social Care Inspection. A copy of the complaints procedure is included in the service user guide. The Home has its own `protection of vulnerable adults from abuse’ procedure. This is the basis for actions taken in the event of an allegation of abuse. This is to help all staff follow the correct course of action to protect residents in the event of an allegation of abuse. Currently Four Seasons are investigating five allegations of poor practise that may be considered to be abusive. The correct course of action has been taken by Four Seasons who have reported each allegation to South Gloucestershire Adult Protection Team, and to the Commission. Four Seasons managers from other Homes are investigating the allegations. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 19 Four Seasons have their own in house training booklet on the subject of ‘protection of vulnerable adults’. The information in the booklet is relevant to helping staff in the work they do. However, as was also the case at the last inspection the majority of staff have not attended recent training on the subject of protection of vulnerable adults from abuse. This training is needed to help to ensure residents are protected from the risk of harm or abuse. It is also relevant at this time that staff receive some form of training due to the number of protection of vulnerable adults referrals that have been made to South Gloucestershire Adult Protection team. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 20 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): 19,20,21,24,26. Quality in this outcome area is adequate. The Home looked clean and mostly satisfactorily maintained . The paintwork in parts of the Home is worn and faded and not suited for the needs of the residents . This judgement has been made using available evidence including a visit to this service. EVIDENCE: Kingswood Court Care Home is a large property that was built to be a Nursing Home. It is situated in Kingswood, near Bristol. The Home is built over three floors that can be reached by stairs or lift. The building is a twenty-minute car ride away from Bristol City Centre. There are local shops, a library, a church, pub and Cossham Hospital nearby. The environment was generally clean and satisfactorily maintained throughout. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 21 However one of the emergency lights on the top floor was not working properly, it was flickering on and off. This means it will not work properly in an emergency. The domestic staff were observed working hard cleaning the Home. It was also good practise to see that domestic staff were talking to residents in a very friendly, warm way while cleaning their rooms. There is a range of specialist equipment and adaptations in place throughout the Home, to assist people with reduced mobility. The majority of bedrooms are for single use, however there are two double rooms. Rooms were adequately decorated and maintained. However it continues to be very noticeable that the paintwork in many parts of the Home is tired looking and very worn. The maintenance worker was seen painting bedrooms during the inspection .The environment would be improved through out if redecoration were to done in all areas that need it as a matter of priority. All bedrooms have en suite facilities, and there are bathrooms and toilets located close to living rooms. There are suitable adaptations in toilets and bathroom to assist people who have reduced mobility. There is also lift access to the first and second floor. There are three open plan dining and television lounges. These rooms looked light and spacious. Residents were observed sitting in communal areas looking comfortable in their surroundings. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 22 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): 27,29,30 Quality in this outcome area is adequate. The staff are trying hard to meet residents needs. However they are not consistently succeeding in this. Residents should be protected by the Homes recruitment procedures. However the five current `protection of vulnerable adults’ investigations suggests they are not always well protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff duty record for nursing and care staff for the previous two-week period was checked. This was done to find out if residents are cared for by enough staff to ensure needs are met. For the current number of 58 residents there is a minimum of three registered nurses and nine care staff on duty every morning shift. There are three registered nurses and seven care staff on an afternoon shift, and two registered nurses and five staff on duty at night. There was some staff sickness recorded. Where possible the Home tries to cover any shortages with their own staff. However there has been some use of agency staff as well. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 23 There are domestic staff, catering staff, and laundry staff who work in the Home every day. However the numbers of these staff were not reviewed. Since May this year, the manager said the Home have now increased on some shifts each week the number of staff by one additional care assistant. A number of residents survey forms were sent back to us before the inspection. There were a number of comments made about the staff. An example of comment made was, ‘ the staff are usually available for me when I need them’. However there were there were six references made by residents and relatives to a lack of staff and how this had affected their needs being met. One resident said in a survey form, ‘, my needs are met only when certain carers are on,’ another comment made was `they are short of staff most of time’ and `staff could be more understanding’. A sample of staff employment records were checked to find out if the Home follows safe and robust recruitment practises when recruiting new staff. There are two written professional references taken up for all new staff prior to offering work with the agency. In addition, all staff sign to declare they have not committed a criminal offence prior to employment. They also complete a Criminal Records Bureau check before commencing employment. These checks are a safeguard for vulnerable residents. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 24 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): 31,37,38. Quality in this outcome area is adequate. Having a temporary manager running the Home while Mr Sibiya is absent benefits residents and staff. The health and safety practises and procedures in place help protect the health and safety of residents, staff and visitors. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mr Sibiya is the registered manager .He is currently absent from the Home. While he is absent Mrs. Linda D’eath has been appointed as the temporary manager. Staff spoke positively of Mrs. D’eath. Staff said they felt Mrs D’eath was approachable, and listened to their concerns. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 25 She has considerable experience in running Care Homes, and in teaching and management at a National level. The monthly monitoring visits of the Home that must be carried out by a representative of Fours Seasons are being undertaken as required by law. There are records of these visits. Records are held securely in locked filing cabinets that are locked when not in use to maintain confidentiality. Records were adequately maintained. Other records have been referenced elsewhere in the report. Please refer to the comments made in the `health and personal care section’ about registered nurses records keeping. The environment looked safe and adequately maintained (see comments written in the environment section of the report). A full time maintenance worker is employed who was observed carrying out maintenance and repair work. Mrs. D’eath said she is in the process of booking staff on a range of health and safety training courses. This is beneficial so that staff keep up to date in their knowledge of health and safety practices. The fire logbook record showed the required fire tests and checks were being carried out and were up to date. This helps to maintain the safety of everyone in the Home. Staff have attended fire safety training in the last twelve months. This training is required so that staff understand what to do in the event of a fire. In February 2007 kitchen staff at the Home won the local environmental health food safety award for which they are to be commended. This award helps to demonstrate kitchen staff are following good health and safety practices and procedures in food safety. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 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 2 3 3 X X 3 3 3 STAFFING Standard No Score 27 2 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X 2 3 Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 27 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 OP27 OP7 Regulation 18. (1) Requirement The Home must be able to demonstrate all residents’ needs are met: This requirement relates to: • Staff meeting the needs of all residents. • It also relates to the need for care plans that must accurately show how staff meet the needs of residents Registered nurses must keep accurate records of the nursing care provided to residents Call bells in bedrooms, must be available and in easy reach of residents who require them. Residents should be treated in a manner that respects their dignity: This requirement relates to, • Residents in wheelchairs being left in a line outside of the lift. • It also relates to male residents wearing aprons meant for female residents The emergency lights on the top floor must work properly Timescale for action 12/10/07 2. 3. 4 OP37 OP7 OP10 17 23.2(n) 12.(4)(a) 13/09/07 13/09/07 13/09/07 5 OP19 23.4c, 20/09/07 Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 28 6 OP18 13. (6) 7 OP9 13.2 All staff must attend suitable training in understanding the principal of the protection of vulnerable adults. Medicines past their use by date must be disposed of. Appropriate records must be kept of the disposal of all medicines. This relates to: a) Out of date injections in one fridge. b) Inaccurate records of stock held in the Controlled Drugs register. c) No records being kept of medicines returned to residents who leave the home. Action is needed to make sure that the correct devices are available for blood testing, to avoid risk of blood- transmitted infections. 13/12/07 01/10/07 8 OP9 13.2 01/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations Action should be taken to make sure that medicines supplied in standard packs could be audited to make sure that they have been given correctly. Kingswood Court DS0000020249.V346286.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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