Inspection on 11/07/07 for Kingswood Court

This inspection was carried out on 11th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Court 27/02/07

Kingswood Court 20/10/05

Kingswood Court 17/05/05

Kingswood Court 19/11/04

Kingswood Court 17/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Kingswood Court Warren Lodge Drive Kingswood Surrey KT20 6QN Lead Inspector Sally Hall Unannounced Inspection 09:30 11th July 2007 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 DS0000013331.V345517.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 DS0000013331.V345517.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingswood Court Address Warren Lodge Drive Kingswood Surrey KT20 6QN Telephone number Fax number Email address Provider Web address Name of registered manager provider(s)/company (if applicable) Name of registered manager registered manager (if applicable) Type of registration No. of places registered (if applicable) 01737 830480 01737 830374 Balcombe Care Homes Ltd Mrs Ann Sayers Care Home 59 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (59), of places Physical disability (2), Physical disability over 65 years of age (4) Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 36 of the 59 registered manager beds can be used for Acute and Continuing Care 27th February 2007 Date of last inspection Brief Description of the Service: Kingswood Court is a large property, which has been adapted to provide nursing care and accommodation for up to 59 residents. It is situated at the end of a private driveway, off the A217, within easy reach of the M25. There are no local shops or other amenities close by. Accommodation is situated in the main house, an attached unit, the Kingfisher Unit and a recently completed extension, the Kestrel Unit. There are communal areas in all parts of the home. The home has a large landscaped garden to the rear and ample parking facilities to the front of the property. The Registered manager Registered manager manager, Mrs Ann Sayers, oversees the clinical practice and day-today administration of the home. Fees range from £527 - £900 per week and are dependant on the type of bedroom occupied and a person’s care/nursing needs. This fee does not include chiropody, hairdressing, toiletries or newspapers. Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key Inspection at Kingswood Court took place on 11th July 2007 between 10am and 5.30pm the lead inspector was Sally Hall On the day of the inspection the Inspector agreed and explained the inspection process with the registered manager manager. Time was spent reading a sample of care plans, written policies and procedures and records kept within the home. Lunch was taken with some residents whilst others were consulted about their view of the home. Staff were also spoken with and a tour of premises was undertaken. The focus of the inspection was to assess Kingswood Court in accordance with the National Minimum Standards for Older People. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. The home was ask to complete an AQAA (Annual Quality Assurance Assessment) evidence from this documents is also included in this report. What the service does well: Talking to the residents in the home it was apparent that they were pleased with the level of care that they receive, they all praised the care staff and nurses. All asked agreed that they are treated with respect and their dignity and privacy is respected. Residents agreed that they are enabled to run their lives in the home to their wishes. They have lots of choices offered during the day, for example choosing when to get up, where to have breakfast, lunch or supper, where to sit etc. The domestic staff take pride in what they do and the home was very clean with no unpleasant odours throughout the home. The chefs at the home produce a very varied menu throughout the day, home cooked and at lunchtime served by the chef and staff. The dining rooms are pleasantly decorated and all tables had table clothes and fresh flowers. There are also menus on the tables showing what is on offer for that day. The home has a very varied programme of activities to suit all tastes; during the day of the inspection there was a quiz in one lounge and later that morning some residents helped in the garden with some planting. There are also activities for those who are confined though illness to their bedrooms, or who prefer things on a one-to-one basis. The home also provides some trips out and recently residents had the opportunity to go to a concert locally. Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 Court DS0000013331.V345517.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 Court DS0000013331.V345517.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 inspected, 6 not applicable. Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents can feel confident that the system of pre assessment at the home enables staff to assess their care needs prior to and following admission to ensure that those needs can be met before they are offered a permanent placement at the home. EVIDENCE: Four new Residents files were sampled; evidence was seen of a comprehensive assessment for each resident. The Residents files sampled were for Residents admitted recently and these contained the assessment undertaken prior to admission and a wide range of other assessments had been added to or were awaiting completion since admission. The assessment process included all the information in 3.2 of this standard. The Registered manager who is a RGN and has the Diploma in Management Studies (DMS) had completed these Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 9 assessments. The information seen had been used to formulate the first care plan, which had been reviewed and change if necessary during the first 28 days and at the end of the first month for each of the residents a formal review is undertaken with all interested parties i.e. resident families key worker etc. Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents benefit from a high standard of care planning and can feel confident that their health care needs will be met. The home has a robust medication policy and procedure in place that is followed by all staff and monitored regularly. EVIDENCE: The care /nursing plans sampled indicated the care and nursing input required by each individual Residents. These plans are reviewed monthly by staff and before if there is a change in the Residents condition/needs. Also evident were the six monthly reviews with the residents, family and any other professional involved. The home assigns a key worker and a lead nurse to each resident, who over sees the care plan. The key work has a monthly meeting with the residents to talk through the support etc they are getting to ensure the resident is happy with the care provision. The daily records were divided and there were two daily reports kept, one by the care staff and the other by the Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 11 nurses. These covered some of the care provided as detailed in the plans of care / nursing plans, however this could be improved significantly if staff recorded more detail, however to ensure that personal hygiene is recorded the files contained a separate sheet that was signed each day by staff showing what care personal care had been provided. It was evident however from the observations of the inspector that Residents are receiving good care and special needs are being provided and this was echoed by the residents spoken with. The inspector found that the use of bed rails had been risk assessed and permission had been sort to install these. Health monitoring was evident in the daily records; evidence was seen of when the GP had been called in to give treatment or advice. The care plans were also used to convey any risk management strategies and detailed the care required to minimise any risk, examples were seen for instance for a resident with a high risk of developing a pressure area. The residents at the home can choose to keep their own GP if the home is with in there area. However the home does pay and retain a local surgery who does regular weekly visits to the home, reviews medication and gives the home the advantage of being able to enlist the help and advice of other health professional quickly such as the dietician, who comes in to the home. The dietician has recently introduced an assessment tool and trained staff how to assess residents who have eating problems or eat very little and are at risk to malnutrition for example. Evidence was seen that other health professionals are also arranged by the home such as chiropodists, opticians, dentists and community psychiatric nurses. The Medication was checked and audited and found to be correct. The Medication storage room was clean and well organised. All medication is locked in cupboards and there is a facility for the storage of controlled medication. The Medication Record Sheets seen had been completed fully. The registered manager explained that she audits the medication at least monthly. The home does not have a dosage system in place and all medication is administered from the original containers. Medication is recorded when it comes into the home and there is also an indication when the repeat has been ordered. Controlled medication was also audited and found to be correct. Only the qualified nurses in the home administer medication to Residents. The inspector saw evidence that all medication that is returned to the pharmacy is recorded and signed for. There is a drugs fridge and the temperature is regularly recorded through the day. Staff were observed to treat the Residents with respect and took care when enquiring about personal issues. All staff were seen to knock on bedroom doors before entering and responded quickly when help was called for. The Residents Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 12 spoken to at the time of the inspection confirmed that the staff at the home do respect their privacy and dignity. The home also has systems in place to audit the way staff protect service users dignity and action plan in place for continual improvement. Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15. Quality in this outcome area is excellent, This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a range of varied activities arranged to suit all residents at the home. Residents also benefit from contact with family/friends. Residents can be confident that they will stay in control of their lives as much as possible by the choices they offered though the day. Residents are provided with a choice of nutritious well balanced home cooked meals that take into account any special diets residents may require. EVIDENCE: Residents are encouraged to participate in a wide range of activities, designed to stimulate and motivate residents and suit their individual tastes. The Activity Co-ordinator arranges a programme of activities in the various lounges around the home; there are also activities for residents who are confined to bed or who prefer to stay in their bedrooms and for those who do not like to join in with group activities. A record of the residents who take part in activities is kept; however it was recommended that the information be Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 14 recorded on individual sheets to comply with data protection and to make it easier to see what activities are offered as well as the amount of activities an individual resident is taking part in. Some of the more able residents spoken to said that they enjoy some of the activities and also confirmed that they do as they want through the day getting up and going to bed when they are ready for example. Evidence was seen of visitors coming into the home during day with no restrictions imposed on these visits. Residents choose to see their guests in private in their own rooms or in one of the quieter lounges, staff assist with this. The staff enable residents to use the beautiful grounds attached to the house when the weather and residents health permits. The home has close links with age concern and makes use of their transport when not being used by them to take residents out. They are also offered trips out by age concern and recently a number of residents went to a concert for example. Some residents also visit local amenities or are taken out by their families. The home held a fete recently and raised money for a chosen charity, many of the residents talked about this, it had been a very successful day which many said they enjoyed and were very please with the sum they managed to raise. Some residents spoke about the things they made for the fete and others spoke of the role on the day. Meals are taken where the residents would most prefer, whether that be in their bedroom or in one of the three dining rooms in the home. The registered manager explained that most residents like breakfast and supper in their bedrooms but that most residents who are not confined to bed like to eat dinner in the dining room. Residents confirmed this to be the case and said that they could choose and change their mind from day to day. All residents spoken to spoke very highly of the meals provided in the home and the chefs that prepares the meals. The inspector was invited to join the residents in the main dining room for lunch. The lunch meal for example consists of a starter, main meal and a hot pudding or a choice of varied cold sweets from the sweet trolley. The residents explained that they are asked what they would like to eat and it is served at the table, the meat is served by the chef and the care staff bring around the vegetables which residents are asked to chose and indicate the amount that they want. All the food is home cooked and looked and tasted very good. There were also varied choices available for the residents on special diets, which is especially good to see as often this is not the case. Mealtimes are a very important part of the residents day and it was evident that the home had done it’s best to make it a very pleasurable experience. The dining rooms them selves were nicely decorated and the tables looked attractive with nice table clothes and fresh flowers. Menus can also be found on the tables with that day’s menu to choose from. The staff Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 15 were on hand to help residents who needed any help and there was a very good atmosphere throughout the meal. The residents spoken to confirm that there were choices available for breakfast and at supper, and one said that if she fancied something the chef was very accommodating. A record is kept of the meals taken by residents; the amount is also recorded if there is an identified eating problem pertaining to individual resident. Family members who are visiting at meal times are offered the opportunity to eat with their relative or friend. The home provides hot and cold drinks through the day and night and snakes are also available on request. Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 16 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 good, This judgement has been made using available evidence including a visit to this service. The home has a robust complaints procedure in place and residents can feel confident that they are protected by the homes safeguarding adult protocols. EVIDENCE: The complaints files was seen and it was evident that the home sees complaints as a positive that helps them improve their service. The complaints however minor they may seem; are recorded, as is the follow up action. The registered manager said that however minor the complaint she knows it is very important to the resident, therefore she has instructed her staff to take them all seriously and record them. The registered manager as part of the home quality assurance monitors the complaints monthly and ensures that they have dealt with the complaint effectively. The registered manager manager also posts compliments on the staff’s notice board and then keeps them in a compliments file. The home follows the safeguarding adults protocol of the local authority, and the file was seen to be accessible to all staff, The manager confirmed this is kept up to date. The staff training records indicated that all permanent staff at the home have undertaken the course, however the registered manager is to Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 17 check the dates carefully given that is now a requirement that this training is required to be undertaken every 3 years. Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 18 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): 19,26. Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents can feel confident that they will be living in a clean and homely environment. EVIDENCE: A tour of the building was undertaken and all areas were viewed plus some of the residents bedrooms. The home was found to be extremely clean and there were no odours apparent throughout. The cleaning staff take a pride in their work and this was very evident. The laundry has a good flow from dirty to clean. Resident’s garments are labelled with their name. The laundry has named boxes to circulate the laundry once it is ready to be given back to the resident. The laundry person ensures that she takes care of any special items the residents may have, items that need hand washing for example. Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 19 The resident’s rooms seen varied in size and shape but all were generally a good size. There are a limited number of double/shared rooms. There are some rooms with en-suit facilities mainly in the new part of the building. The rooms contained the furniture supplied by the home and some personal items brought in by the residents. There is a lockable facility in each room. It was noticed that not all residents had a light which they can access from the bed this was in some cases because the beds had been moved form there original position at the request of the resident. This was discussed with the registered manager who is considering providing an over head light that can be turn on and off from the bed. The electric cupboard had lost its signage this was pointed out to the registered manager who had this replaced straight away. Yellow sack system was seen in place for disposal of clinical waste, there was bins with lids in bathrooms and these were clearly labelled for clinical waste only. There is a separate area from the garden where the bins in which the bags are stored awaiting collection are deposited; these bins are emptied once a week. The home has a clinical waste collection certificate. The home uses the red sack system for the foul linen in the laundry this ensures that staff handed foul linen as little as possible. The environmental health officer has visited since the last inspection, they were not concerned about the flooring in the kitchen that was raised in the last inspection report. They did however ask that the Kitchen ceiling be repainted in beverage area, this was done and certificate seen to confirm this. The kitchen areas looked well organised and clean, a full inspection was not undertaken on this occasion. Fire extinguishers were seen mounted on the walls around the building and the labels showed that they had been tested in 09.06 so are in date. There were no obvious health and safety issues seen around the building. Commode chairs were seen stored in one bathroom and the registered manager was to review this practice. The lounges and dining areas were pleasantly decorated and comfortable furniture was available for residents to sit in. the areas are used by the whole home, residents can choose where they wish to eat and sit across the three main areas/units. The home is situated in mature well-established grounds that are well maintained and offer various patio areas to sit out in, during the nicer weather. The residents talked about the weather of wild life that visits the garden such as fox’s and squirrels fro example. Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 20 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): 27,28,29,30. Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents can be confident that they will be cared for by staff sufficient in number to provide for there care needs and who are trained, however residents would benefit still further if more care staff had attained an NVQ level 2 or another appropriate qualification. EVIDENCE: The rotas were studied, for the week of the inspection and it was evident that the numbers of staff that are needed to meet the resident’s needs are maintained, with staff that are absent for any reason being covered. The registered manager explained that each day a decision is made as to who will work in each unit in the home, this is done to ensure a good skills mix in each area. The residents said that they felt that there was always staff to hand, and they did not seem rushed. The registered manager said that although the staff work in the separate areas they all move around as required to cover when problems arise. Several times during the day the emergency assistance bell was rung and staff from all over the home were seen making their way to the call. The registered manager said that they rarely need to cover the home with agency staff, and when they do there own staff are asked to do extra. Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 21 The home employees a total of 23 care staff, just 5 of these has an NVQ (National Vocational Qualification) level 2 or above in care. This is well below the recommended level, which should by now be over 50 . The registered manager stated it would have been higher but staff who have gained the award with the home in the past have left the home for various reasons. The registered manager confirmed that there are a number of staff actually doing the award at present and that there is a commitment to increase these numbers as the benefits to the staff themselves and the home is apparent. The registered manager confirmed that the qualified nurses are enabled to do training to keep their nursing qualifications current. The home is also registered to undertake the adaptation course for nurses who have qualified overseas. The training records were not easy to see, as it is kept on an individual basis in staff files. The registered manager agreed to look at a system that would make the information more accessible. Talking with the registered manager since the inspection, this work is be undertaken, her finding were that all care staff have undertaken the statutory training but that other staff have not all completed them. Courses are now being booked to make sure the shortfalls in the staff training is met. The homes receptionist is doing an NVQ level 2 called front of house/ customer service. There is also a member of the kitchen staff doing an NVQ level 2 called food and drink, it is good to see a commitment to all the staff in the home in this way. Another 8 care staff have completed a nutrition and health course. A number of staff files were sampled, the registered manager explained that the volunteer who at the last inspection did not have the required documentation and checks has now got all that is necessary. The other files sampled included a nurse a domestic assistant and two care worker, the latest staff to be employed at the home. All the files contained the information required, such as identification, application forms, references and CRB (criminal record bureau) checks, interview notes. The application forms also contains a questionnaire, which is optional on equality. Evidence was also see that new staff undertake an induction programme/foundation course which meet NTO specifications. In the case of the care staff the competence based work undertaken can then be used towards an in NVQ (National Vocational Qualification) in care. This training and many other courses are supplied in house by staff in the organisation who have been trained to train the courses they teach and certificate. Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 22 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): 31,33,35,38. Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. The residents benefit from having a well supported and well led staff team in a home that is well managed to make sure residents receive a quality service. EVIDENCE: The registered manager is a qualified RGN, she has also attained a DMS Diploma in Management Studies. Along with her many years experience in the caring field this makes her a very suitable registered manager. The registered manager has ensured that there are quality systems in place to monitor the care provision etc in the home. Evidence was seen of some of Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 23 these, for example the Dignity team audit. A quality audit feedback is also produce form surveys sent out during the year. The home has regular staff and resident’s meetings these are recorded. The residents have lockable facilities in their bedrooms but for those who prefer a small amount of money and valuables can be held in the homes safe. The resident’s personal money is held in individual envelopes and is documented on individual record sheets. Receipts are also kept. However there was a confusing system in place with several sheets currently in use for some residents. When audited it was correct but it took some time to work out the correct balance. This was discussed with the registered manager and the staff member responsible who agreed to look at providing a simpler more accurate system of recording transactions. Risk assessments are undertaken for each room in the building and other risk assessments are written as necessary for such things as building works etc. The home has a COSHH file and a room where chemicals are kept secure when not in use. The registered manager checks the COSHH file six monthly or when something is ordered different from usual. As part of the fire safety procedures at night the staff check cupboards etc every hour though the night and sign to say they have check that there are no smoke or fire anywhere and that fire exits are clear. The fire log was seen and evidence was seen that alarms and other required tests are undertaken regularly. Staff at the home up to four times a year undertakes fire training, each training session provided is on a different aspect of fire awareness. The home has a full range of policies and procedures in place that are reviewed on annual basis and before if there is a change in legislation. The accident book was seen and the registered manager sends a falls report to the director weekly. The registered manager also undertakes an audit of the falls through the month and takes action if a pattern in the falls emerges. The registered manager also advises staff on falls prevention and this was also evident in the care plans seen. Moving and handling training is provided in house and the registered manager confirmed that all current staff have a moving and handling certificate. The registered manager and her deputy are undertaking risk assessment and health and safety training as trainers, once completed satisfactorily they will enable to provide this valuable training directly to their staff. The registered manager confirmed that staff receive regular supervision, that in some cases team leaders have been trained to undertake the sessions with care staff. The sessions are diarised and a record is kept of the meetings. Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 24 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 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 2 3 x 3 Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 25 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 manager person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered manager Provider(s) must comply with the given timescales. No. 1 Standard OP28 Regulation 18(1) Requirement A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) should have been achieved by 2005. by now that should have been exceeded the registered manager is required to ensure that more staff undergo this training. Timescale for action 31/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered manager Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP12 OP35 Good Practice Recommendations The daily records would benefit from a little more detail. The records of who take part and who refuse activities should be kept on individual sheets. The registered manager ensures that service users money held by the home is not only kept securely but that there is a clear system in place to account for money in and out which is receipted. The balance shown should be the balance kept in the safe individually in pockets/envelopes and is kept separate form other valuables kept, which DS0000013331.V345517.R01.S.doc Version 5.2 Page 26 Kingswood Court should be recorded separately. Kingswood Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Court DS0000013331.V345517.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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