Inspection on 27/02/07 for Kingswood Court

This inspection was carried out on 27th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 11/07/07

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 Sarah MacLennan Unannounced Inspection 09:30 27 February 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kingswood Court DS0000013331.V327679.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.V327679.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 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 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.V327679.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 36 of the 59 registered beds can be used for Acute and Continuing Care 20th October 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 accommodation for up to 59 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 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, Mrs Ann Sayers, oversees the clinical practice and day-to-day administration of the home. Fees range from £600 - £900 per week. This fee does not include chiropody, hairdressing, toiletries or newspapers. Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit formed part of the key inspection process and took place over 6½ hours commencing at 09:30 and ending at 16:00. The visit was carried out by Sarah MacLennan and Lesley Garrett, Regulation Inspectors. Mrs Ann Sayers, the Registered Manager, was present throughout the inspection. As part of the inspection process a partial tour of the premises took place. Various written records were examined, including four 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 inspectors spoke to a number of service users. Some staff members were spoken to during the course of the inspection. Service users, relatives and health care professionals were surveyed prior to the visit. Some of the comments made to the inspectors are quoted within this report. The inspectors would like to thank the staff and service users for their time, assistance, and hospitality during the visit. What the service does well: What has improved since the last inspection? Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 6 The extension providing a further fifteen beds has now been completed. The home has recently had a new call bell system fitted. 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.V327679.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.V327679.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&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users had been assessed prior to admission to the home to ensure that the home can meet the service users identified needs. The home does not offer intermediate care. EVIDENCE: The inspectors were advised that the registered manager carries out a preadmission assessment on all prospective service users. The four care plans sampled had a pre-admission needs assessment completed. The assessment covered all elements of physical, mental, and social needs. Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 9 Service users surveyed felt they had received enough information prior to moving to the home. One service user stated that he received a ‘helpful brochure’. Kingswood Court DS0000013331.V327679.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. Comprehensive care plans were in place. There was regular review of whether the service users needs had changed. The storage and administration of medication were in line with the homes medication policy. Care was seen to be provided in a respectful and sensitive 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. Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 11 Service users 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 user comments included; ‘…very happy here’, ‘the staff are very good, the attention we receive is very very good’ and ‘I find everything very nice’. Service users were registered with local GPs and had access to other health care services. The home had established links with various community specialist services, including physiotherapy, occupational therapy, dietician, wheelchair services and chiropody. Comments received from visiting healthcare professionals included ‘ the home always has an air of calm and order’ and ‘the manager is quietly efficient and always available’. The homes storage 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. The medication administration records were seen and it is recommended that two trained nurses sign all handwritten entries. The home had a ‘privacy and dignity team’ who perform a regular audit of practices and systems within the home. The written record of the audit carried out in February was seen and found to be comprehensive. The home is very pro-active in this area. Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. The activities provided by the home were varied, and stimulating. Service users were encouraged to maintain their interests. Contact with family and friends was encouraged. Meals were well balanced and varied, individual choices and preferences were catered for. EVIDENCE: The home employs a full time activities organiser. A programme of activities was displayed offering a range of pursuits. The activities on offer included group and one to one sessions. Service users surveyed and spoken to were happy with the activities provision within the home. One service user stated that activities were provided ‘all Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 13 the time, mornings and afternoons. Sometimes I don’t get time to read my newspaper until the evening’. At the time of the visit, a number of activities were taking place. A large group of service users were having a film afternoon, whilst a smaller number were enjoying a game of dominoes. There were no restrictions to visiting times and staff support and encourage service users to maintain family links and friendships both inside and outside the home. Relatives surveyed said that the staff welcomed them in the home at any time. The menu is on a four weekly rota; there is different menu for summer and winter. A printed copy of the menu is on the dining tables; a choice is available and is made at the mealtime. Special diets, including soft diets, high calorie, low cholesterol and diabetic diets are catered for. Service user comments regarding the food included, ‘absolutely delicious’, ‘brilliant’, ‘nice size portions’, ‘the food is excellent’ and ‘quality is high, fresh and varied’. Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a simple and accessible complaints procedure. Staff were aware of the homes whistle-blowing policy and of vulnerable adults procedures. Gaps in the recruitment file of one staff member could potentially put service users at risk. EVIDENCE: The home had a simple and accessible complaints procedure. There had been several concerns / complaints detailed since the last inspection. It was positive to note that the registered manager followed the complaints procedure even for minor concerns, and all complaints were managed efficiently with a satisfactory outcome. Service users surveyed and 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 received training in the protection of vulnerable adults. Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 15 One of the four recruitment files sampled did not contain any of the required checks as stipulated under Standard 29 of the National Minimum Standards for Older People (see standard 29), potentially putting service users at risk. Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 16 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. The home was suitable in layout for its purpose. The home was found to be clean and tidy. EVIDENCE: The inspectors 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 registered manager stated that the previous requirement to repair the kitchen floor had not been met. It is required that the registered manager Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 17 shall consult with the environmental health department regarding the suitability of the kitchen floor. Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. 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. Gaps in the recruitment process were noted, specifically with regard to the recruitment of volunteers. EVIDENCE: The staff rota seen 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 stated that the she has the flexibility to increase the staffing numbers at key times of the day. The registered manager is committed to training, including NVQ training. Staff spoken to stated that they had received training. Four Staff files were seen during the visit; including the file of a volunteer. The file of the volunteer did not contain proof of identity, two valid references, Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 19 an enhanced Criminal Records Bureau (CRB), a Protection of Vulnerable Adults (POVA) list check or a full employment history with an explanation of any gaps. The registered manager stated that this was an oversight and did not reflect the homes normal recruitment practices. The other three files seen did not contain any shortfalls. A requirement has been made. Kingswood Court had a comprehensive induction and ongoing training programme that meets the specifications set out by the Skills for Care organisation. The training records seen at this visit evidenced that all mandatory training and updates are provided. Additional training is provided that is relevant to the needs of individual service users. Service users surveyed and spoken with were complementary about the staff at the home. Comments included ‘staff are always very good’. All interactions observed between the staff and service users were caring and respectful. Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 20 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 service users benefit from the management approach at the home, which provided an open, positive and inclusive atmosphere. The home had 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. Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager, Ann Sayers, 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. Comments received from visiting healthcare professionals included ‘the manager is quietly efficient and always available’. The home completes yearly full surveys of all service users, relatives, and stakeholders, including GP’s, visiting clinicians and staff. The results are correlated in to a report, and all service users receive a copy of the report. The home had quality assurance teams that look at aspects of policies and procedures on a monthly basis. These results are then documented and feedback is then given to the staff regarding areas for improvement. The inspectors commend 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 for service users. 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.V327679.R01.S.doc Version 5.2 Page 22 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 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 OP19 Regulation 23 (5) Requirement The registered person must consult with the environmental health department regarding the suitability of the kitchen floor. The registered person must not employ a person to work at the care home unless he / she is fit to work at the care home and the registered person has obtained the information and documents specified in paragraphs 1 – 9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000(Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004) Timescale for action 27/05/07 2 OP29 2 (3) 19 (1)(b) Schedule 2 27/03/07 Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 24 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 It was recommended that two trained nurses should sign all handwritten entries on the medication administration records. Kingswood Court DS0000013331.V327679.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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.V327679.R01.S.doc Version 5.2 Page 26 - 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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