Inspection on 20/10/05 for Kingswood Court

This inspection was carried out on 20th October 2005.

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 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 11/07/07

Kingswood Court 27/02/07

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 Sarah Radlett Announced Inspection 20th October 2005 10:00 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.V261061.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 DS0000013331.V261061.R01.S.doc Version 5.0 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 provider(s)/company (if applicable) Name of 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 44 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (44), of places Physical disability (2), Physical disability over 65 years of age (4) Kingswood Court DS0000013331.V261061.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Of the 44 (forty four) registered, 6 (six) service users may be within the category DE(E) and 4 (four) may be within the category PD(E). up to 36 (thirty six) of the 44 (forty four) registered beds can be used for Acute and Continuing Care Of the 44 (forty four) registered service users, 2 (two) may be within the category PD (between the ages 55 and 65) Service users requiring acute or continuing care must be accommodated on the ground or first floor only. 17th May 2005 Date of last inspection Brief Description of the Service: Kingswood Court is a large property which has been adapted to provide nursing care and accomodation for up to 44 service users. 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 amennities close by. Accomodation is situated in the main house, and an attached unit, the Kingfisher Unit. There are communal areas in both 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 oversees the clinical practice and day to day administration of the home. Kingswood Court DS0000013331.V261061.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 5½ hours and was the second inspection carried out by the Commission for Social Care Inspection for the year 2005 to 2006. Sarah Radlett carried out the inspection. Mrs Anne Sayers, the Registered Manager, was present throughout the inspection. A tour of the premises took place and various written records were examined, including five care plans and service user assessments, the complaints record, a sample of the required safety certificates, the medication storage facilities and a sample of the medication administration records. The inspector spoke to a number of service users. Some staff members were spoken to during the course of the inspection. The inspector would like to thank the staff and service users for their time, assistance, and hospitality during the inspection. What the service does well: What has improved since the last inspection? Service users are protected by the homes procedures for the protection of vulnerable adults. All staff have had abuse awareness training. Kingswood Court DS0000013331.V261061.R01.S.doc Version 5.0 Page 6 In order that service users are protected a general risk assessment of the building and all safe working practices had been completed. Comments had been made by Service Users regarding the night staff, following this a night report including the times of call bells and the time take to answer them is now completed. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kingswood Court DS0000013331.V261061.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 DS0000013331.V261061.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): 2, 3, 4, 5 & 6 Service Users had a written contract / terms and conditions. All Service Users had been assessed prior to admission to the home and were able to stay at the home on a trial basis prior to becoming permanent. The home is able to provide intermediate care. EVIDENCE: Service Users had a written contract, which contained the homes terms and conditions, samples were seen. The care plans inspected had a pre-admission needs assessment completed. The assessment covered all elements of physical, mental, and social needs. The home is able to provide intermediate care, but does not currently have any Service Users in this category. The home has established links with various community specialist services, including physiotherapy, occupational therapy, dietician, wheelchair services and chiropody. Kingswood Court DS0000013331.V261061.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Comprehensive care plans are in place, however, due to gaps in the daily statements there was a lack of evidence that the care plans were always followed. There was regular review of whether the Service Users needs had changed. The storage, recording and administration of medication were in line with the homes medication policy. Care was provided in a respectful manner. EVIDENCE: Samples of care plans and daily statements were looked at. The care plans were detailed and comprehensive, with risk assessments being completed. The service users signed them wherever possible to evidence their involvement in their care. There was regular review of whether the Service Users needs had changed. Gaps were seen in the daily statements and there was a lack of evidence that the care plans were always followed. Kingswood Court DS0000013331.V261061.R01.S.doc Version 5.0 Page 10 Service users and relatives spoken with were complimentary regarding the care that they received in the home. This was also reflected in the comment cards received prior to the inspection. Service Users were registered with local GPs and had access to other health care services including chiropodist and dentist. The homes storage, recording and administration of medication were seen and in line with the homes medication policy. The home had links with a local pharmacist who is able to offer advice if required. Kingswood Court DS0000013331.V261061.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 The activities provided by the home were varied, and stimulating. Service users were encouraged to maintain their interests. EVIDENCE: There was an activities organiser in place. A programme of activities was displayed offering a range of pursuits. Service Users spoken to were happy with the activities provision within the home. At the time of the inspection, the inspector observed a reminiscence session. The Service Users were actively participating and there was a lively atmosphere. Kingswood Court DS0000013331.V261061.R01.S.doc Version 5.0 Page 12 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 home had a simple and accessible complaints procedure. Staff were aware of the homes whistle-blowing policy and of vulnerable adults procedures. EVIDENCE: The home had a simple and accessible complaints procedure. There had been 9 complaints detailed since the last inspection. It was pleasing to note that the manager followed the complaints procedure even for minor concerns, and all complaints were managed efficiently with a satisfactory outcome. Several service users spoken to during the inspection were aware of the complaints procedure, and felt confident about using the process. The home had adopted Surreys Multi-Agency Procedure for Vulnerable Adults; a copy of the policy was available. Staff receive training in the protection of vulnerable adults. Kingswood Court DS0000013331.V261061.R01.S.doc Version 5.0 Page 13 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 was suitable in layout for its purpose. The home was found to be clean and tidy. EVIDENCE: The inspector toured areas of the home. It was seen to be clean, tidy and free from offensive odours. The premises were seen to be well maintained with service users able to access all areas of the home and grounds. The manager stated that the previous requirement to repair the kitchen floor was being incorporated into the new building work, which was planned to start in the near future. The gardens were extensive and well maintained. Several service users commented about the lovely views of the garden. Kingswood Court DS0000013331.V261061.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The staffing arrangements in place on the day of the inspection were sufficient to meet the needs of the Service Users. The Registered Manager ensures that staff receive appropriate training, including NVQ training. The recruitment process was being followed to ensure that only suitable staff were being employed. EVIDENCE: The staff rota inspected demonstrated that the staffing numbers and skill mix were appropriate to meet the assessed needs of the Service Users living in the home. The Registered Manager is committed to training, including NVQ training. All new staff members receive induction training and there was evidence of ongoing training for staff, including Service User specific training. The Staff file of a new member of staff was examined at inspection. The file contained the necessary checks and references and evidence of induction training covering aspects such as moving and handling, fire training, and elements of care. Kingswood Court DS0000013331.V261061.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 The home has effective systems in place to monitor the quality of care and services provided. Appropriate systems were in place to safeguard the financial interests of Service Users. Policies and procedures were in place to ensure, as far as is reasonably practical, to ensure the health, safety and welfare of Service Users. EVIDENCE: The Registered Manager is qualified, competent and experienced to run the home, she has a diploma in management studies. All Service Users spoken to spoke very highly of the homes manager. Kingswood Court DS0000013331.V261061.R01.S.doc Version 5.0 Page 16 The home regularly completes full surveys of all service users. The results are correlated in to a report, and all Service Users receive a copy of the report. The inspector commends the management for their ongoing efforts in looking for ways to further improve the care and services offered to those living at the home. Procedures are in place to safeguard the financial interests of Service Users. No staff members are appointees and written records of financial transactions are maintained. Samples of these records were seen and found to be in order. Samples of health and safety certificates were inspected and found to be in order. Staff were observed to be following appropriate health and safety practices as they went about their work. Kingswood Court DS0000013331.V261061.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 X X 3 Kingswood Court DS0000013331.V261061.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (1) Requirement The registered person must ensure that the care plan and documentation system is revised to include evidence that identified needs and goals are being met. The kitchen floor requires repair. This is the third time this requirement has been made. Timescale for action 20/11/05 2 OP19 23 (2)(b) 20/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kingswood Court DS0000013331.V261061.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 DS0000013331.V261061.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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