Inspection on 31/05/05 for Kingswood Court

This inspection was carried out on 31st May 2005.

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 10/09/07

Kingswood Court 23/05/07

Kingswood Court 04/05/06

Kingswood Court 10/11/05

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 Announced 31 May to 1th June 2005 09:45 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 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 D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kingswood Court Address Soundwell Road Kingswood South Glos BS15 1PN 0117 9603722 0117 9603744 Grandcross Ltd Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Aubrey Sibiya Care Home with Nursing 66 Category(ies) of OP Old age for 66 registration, with number of places Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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 who has physical disability. This condition relates to a named person and will lapse if the person leaves the home. Date of last inspection 24-Feb-2005 Unannounced Brief Description of the Service: Kingswood Court is a purpose built home, operated by Grandcross Ltd, which is affiliated to Four Seasons Health Care. The home is registered to provide nursing care for 66 people over the age of 50. It has ample car parking space at the rear and a small garden in front separating it from the main road. There is access to local shops, amenities and bus routes. Accommodation is provided over three floors; each floor has its own lounge and dining area. There is level access throughout the home and a lift to each floor. Toilets and bathroom facilities are adequate for the number of service users and have adaptations to meet their assessed needs. All rooms are equipped with call alarm systems. Visitors may visit at any time. An activities organiser is employed and organises a varied programme of activities throughout the week. Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector was able to speak with twenty-eight residents, and a number of relatives to find out their views of the Home, and of the service provided. The inspector also spoke with care staff, three registered nurses, and the registered manager, about their roles and responsibilities, their training needs, and how they assist and support residents. Staff were also observed assisting residents with their needs. A range of records relating to the day-to-day running, and the management of the Home were inspected. A selection of resident’s care records and care plans were also reviewed. The majority of the environment was seen; the only areas not viewed were a small number of resident’s bedrooms. What the service does well: What has improved since the last inspection? What they could do better: All residents would benefit, if there were a sufficient number of staff on duty at all times, to ensure individual’s range of personal care needs can be fully met. All residents would also benefit if there were a significant improvement in the length of time taken for call bells to be answered by staff, as currently, many residents feel they wait for an excessively long time for staff to assist them. It is anticipated that an adjustment in the staffing levels that currently operate, will improve the quality of the overall service. Residents would benefit if care plans were updated to indicate individuals changing care needs are being monitored. Residents would also benefit if their assessments of needs, contain all the relevant information about their care needs. Care plans generally need to be clearer in detail, and state what actions must be taken to support residents to meet their needs. Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 6 Staff would benefit if the supervision process were reviewed. The Home should ensure that the format for supervision meets the needs of the home and its employees. There would be an additional ‘safe guard’ for all residents if the Homes ‘protection of vulnerable adults from abuse’ policy were updated to reflect current government guidance in this area. 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 D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 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 standard(s) 1,3,4 Residents are provided with some of the information needed to make an informed decision about moving into the Home. An assessment of the majority of residents care needs is carried out, and staff partially meets individuals needs. EVIDENCE: A copy of the statement of purpose and the service users’ guide were inspected, these documents should inform residents about the services the Home provides. There was some helpful information included in both documents that would assist prospective residents in choosing a care Home. However the documents are not currently up to date, as there has been a recent change of ownership of the company. The Commission for Social Care Inspection intends to liaise with Four Seasons Health Care limited at a national level, to agree a timescale for these documents to be updated to reflect these changes. There was also information sent to the Commission for Social Care Inspection on behalf of one resident, prior to the inspection, which expressed the view that Four Seasons as a company do not make clear the range of fees and services residents will be charged for, while staying at the Home. Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 9 A business relationship manager who works for the Commission for Social Care Inspection, and liaises with Four Seasons Health Care Limited, has informed the inspector that there had been considerable legal debate between the company and Trading Standards about the content of their statement of terms of conditions, and this had ‘slowed’ its implementation. The Commission for Social Care Inspection will be monitoring closely the progress by the company to implement suitable statements of terms and conditions for all residents residing in their care Homes. The inspector talked with residents and visitors while walking around the Home. There was a broad range of comments expressed by residents about the care they receive. Examples of comments made expressing satisfaction with the service included, ‘the staff are very friendly’, ‘the staff are pretty good’ and, ‘it’s like a five star hotel you get everything you need’. There were also a significant number of comments made by residents and visitors, which expressed the view that call bells frequently take an excessively long time to be answered. A high number of residents also expressed the view that the Home was short of staff. Six residents assessment records were reviewed to ascertain how residents range of care needs are assessed. The assessment records were generally reasonably informative, and showed the range of physical, mental and social needs the person had. The assessments showed how the Home intends to meet each persons needs. One resident’s assessment information was incomplete as there was no assessment of the person’s mental health care needs. Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10 Resident’s plans of care meet some of the individuals needs, and the majority of residents needs are being formally reviewed. EVIDENCE: Six resident’s care plans were reviewed to see how residents are supported to meet their health care needs. Care plans addressed some of the individual residents range of physical and psychological health care needs. However one care plan was vague and unclear in detail, and had not been written based on an assessment of the person’s needs. A second care plan did not include any actions that must be taken to support the person with their mental health needs. One resident’s care plan requires being rewritten as it had been devised in the year 2000, and as such was not written based on the residents current needs. However all the care plans seen were being reviewed on a regular basis by registered nurses. The inspector talked to residents and their relatives while walking around the Home. There were many comments of satisfaction expressed by residents about the care they receive. However it was also reported from a number of sources, that residents full range of personal hygiene and care needs are not always being met in full. The inspector observed staff on both days of the inspection to be hardworking and helpful when assisting residents. From these observations, the reviewing of dependency levels of residents, and discussion Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 11 with, residents, visitors, and staff it is evident staffing levels need to be adjusted to ensure residents full range of care needs can be fully met at all times. Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 The Home provides a range of social activities for residents that they appreciate, and residents are able to maintain close contact with families and friends. The Home provides a reasonably varied diet for residents. EVIDENCE: The inspector spent time discussing with residents the range of activities provided. Some of the residents the inspector met said how they enjoyed the range of games and quizzes that take place. Several residents said there had been a recent residents outing to a garden centre organised, and there is also a forthcoming day trip planned to Bristol zoo. The Home has introduced ‘one to one’ sessions for residents with the activities organiser, if this is what the person prefers. While meeting residents, the inspector was also able to meet a number of relatives all of who are able visit at any time they so wish. Residents were asked their views of the quality and variety of meals provided at the Home. A significant number of residents said they felt meal choices were good, and they liked the food that is provided. Two residents told the inspector they did not like the food that was served in the Home, but they were not specific about what they did not like. The inspector observed that the main meal choice on the first day of the inspection which was baked ham, tinned mushy peas and mashed potatoes, looked bland, and unappetising. However the choice of roast beef or lamb Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 13 chops, which was served on the second day, and sampled by the inspector, was tasty and well cooked. Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The Home addresses in detail complaints made about the service, there are systems in place, to try and protect residents from harm or abuse, however the ‘protection of vulnerable adults’ from abuse procedure is not up to date. EVIDENCE: A copy of the complaints procedure is on display in a well-frequented part of the Home, which means residents and visitors, will know how to obtain the necessary information if wishing to complain. The Commission for Social Care Inspection has investigated three complaints since November 2004. These related to care and nursing practise, one complaint was not upheld, and two were partly substantiated. There was also evidence seen that Mr Sibiya had responded to three recent complaints he had received promptly and thoroughly. Staff are being provided with regular training on understanding issues around the protection of vulnerable adults from abuse, this should help to increase staffs awareness that they are caring for particularly vulnerable people. There is a company policy detailing the actions that must be taken to protect residents in the event of an allegation of abuse in the Home. However this policy is not up to date in accordance with current Government ‘vulnerable adult’ guidance, meaning staff may not be fully aware of what actions they must take if an allegation of abuse is made. Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19-26 The Home is safe, satisfactorily maintained, and suitable for the meeting the needs of residents. EVIDENCE: The Home is built in its own relatively small sized, garden area, and is close to local shops, services and amenities. The building is a purpose built property, on three floors; there is lift access to all floors, and a range of suitable adaptations in place throughout the Home, to assist residents and visitors who may have limited mobility. The inspector walked around the inside of the Home, and viewed all of the communal living areas and the majority of service users bedrooms. The environment was clean, tidy and satisfactorily maintained in the majority of areas. One resident’s bedroom wall requires repair, as there is a small area of the wall by the door where there is a hole through to the plaster below. Many residents told the inspector the Home was always kept clean and tidy, and domestic staff were working hard carrying out their duties on both days of the inspection. Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,30 There is a shortfall in the required number of registered nurses and care staff to meet residents’ needs. Staff are provided with the training required to do their jobs. EVIDENCE: Staff were observed carrying out their duties on both days of the inspection, assisting residents. Staff assisted residents in a friendly manner and were evidently hardworking. To review how many staff are on duty for each shift, the duty record for the previous four-weeks was inspected, for full occupancy of the Home. There is a minimum of three registered nurses and ten care assistants for the early shift with three registered nurses and seven care assistants for the late shift. At night there is one registered nurse and two care assistants on duty. The manager works a set number of supernumerary management hours each week as well as occasional shifts to keep up to date with day-to-day matters in the Home. Please note: Comments that have been referred to earlier in this report around residents waiting for a long time for call bells to be answered, and the issue of attending to residents personal care needs are also relevant to this section of the report. A selection of staff training records were inspected to see what recent training staff had attended. Registered nurses and care staff had attended some recent clinical training and updating, and there is a programme of NVQ in care training in the Home. Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 17 There is a programme of in house training on the issues of managing challenging behaviour that some staff had attended. It would be beneficial if all staff were able to increase their awareness of how to respond in the best interests of the resident and themselves, when supporting residents who have complex psychological needs. Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,35,36,37,38 The Home’s policies and procedures protect resident’s best interests. The health and safety of residents and staff is maintained, however the staff supervision system does not best suit the needs of staff, residents or the Home. EVIDENCE: Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 19 The environment was generally satisfactorily maintained in all areas viewed. There are health and safety policies and procedures in place for staff to follow to ensure the safety of themselves and residents is maintained. The maintenance worker carries out a range of health and safety maintenance checks of the environment. The fire logbook showed weekly tests of fire alarms being carried out. The fire fighting equipment was also being checked regularly, thereby helping to maintain the safety of those inside the building. There was a record that showed staff had attended fire safety update training in the last twelve months, to ensure they were aware of fire safety procedures in the Home. Supervision records that were inspected were not up to date, and showed staff are not provided with regular structured supervision sessions of their work and practise. The Home is able to look after residents’ personal spending money, and provides a secure safe for this purpose. The inspector reviewed six residents finance records, with the assistance of the financial administrator. Resident’s financial records were satisfactorily maintained, relatively straightforward to follow, and were satisfactorily organised. A number of residents also told the inspector that they regularly had a social chat with the administrator they enjoyed. Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x 3 2 3 3 Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation Schedule 1.1,2,4. Requirement The statement of purpose must be updated to reflect the change of ownership of the company, and include up to date information about the management structure. The current staffing levels must be reviewed and adjusted, to meet residents needs. The four residents care plans identifed at the inspection, must be updated, clearly state what actions must be taken to support the person,and be based on the residents individual needs. The residents assessement information identifed at the inspection, must be completed, and include an assessment of the persons mental health needs. The bedroom wall identifed at the inspection, must be repaired. There must be a suitable, up to date system of staff supervision fo all staff. The protection of vulnerable adults policy must be updated, and must reflect current Timescale for action To be agreed with Four Seasons Health Care limited nationaly . By 1/07/05 By 1/07/05 2. 3. 27 7 18.(1),(a) 15.(1), 4. 3 14.1(a) by 1/07/05 5. 6. 7. 19 36 18 23.2(b) 18.2 13.6 by 7/06/05 by 1/08/05 by 1/07/05 Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 22 Government issued guidance. 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 30 Good Practice Recommendations All staff should attend the in house training sessions on challenging behaviour. Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kingswood Court D56 D05 S20249 Kingswood Court V221845 310505 Stage 4.doc Version 1.30 Page 24 - 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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