Inspection on 04/02/08 for Kingswood Court

This inspection was carried out on 4th February 2008.

CSCI found this care home to be providing an Adequate service.

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 10/09/07

Kingswood Court 23/05/07

Kingswood Court 04/05/06

Kingswood Court 10/11/05

Kingswood Court 31/05/05

Kingswood Court 24/02/05

Kingswood Court 14/12/04

Kingswood Court 21/06/04

Kingswood Court 24/05/04

Kingswood Court 15/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Kingswood Court Soundwell Road Kingswood South Glos BS15 1PN Lead Inspector Melanie Edwards Key Unannounced Inspection 09:00 4 AND 5TH February 2008 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 DS0000020249.V358803.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingswood Court Address Soundwell Road Kingswood South Glos BS15 1PN Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0117 9603722 0117 9603744 kingswood.court@fshc.co.uk Grandcross Limited(wholly owned subsidiary of Four Seasons Health Care Ltd) To be appointed Care Home 66 Category(ies) of Old age, not falling within any other category registration, with number (66) of places Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. May accommodate up to 66 persons aged 50 years and over who are receiving nursing care. Of the total 66 persons, up to 3 persons (who must be 65 years or over) May be accommodated and provided with personal care only. Manager must be a RN on parts 1 or 12 of the NMC register Staffing notice dated 22/6/1998 applies. May accommodate one person under the age of 50, who has physical disability. This condition relates to a named person and will lapse if the person leaves the home. 10th September 2007 Date of last inspection Brief Description of the Service: Kingswood Court is a purpose built home, operated by Grand Cross Ltd, which is affiliated to Four Seasons Health Care. The home is registered to provide nursing care for 66 people over the age of 50. It has ample car parking space at the rear and a small garden in front separating it from the main road. There is access to local shops, amenities and bus routes. Accommodation is provided over three floors; each floor has its own lounge and dining area. There is level access throughout the home and a lift to each floor. Toilets and bathroom facilities are adequate for the number of residents and have adaptations to meet their assessed needs. All rooms are equipped with call alarm systems. Visitors may visit at any time. The fees charged for staying at the Home for care range from £521.07 to £600 per week. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection was carried out over two consecutive days and was unannounced. We (the Commission) met thirty-three of the fifty-six residents living at the Home. We met Mrs D’eath who is the acting manager, three registered nurses, nine care assistants and a chef about roles, responsibilities, training needs, and how they assist residents. Staff were observed assisting residents with their needs. The lunchtime meals were observed being served. A selection of records relating to the running and management of the Home were looked at. These included staff training files, staff recruitment files, staff duty rotas, the fire logbook record, maintenance records, menus, and medication records. Five Regulation 37 notices (Homes must inform us of significant events in residents lives, and any deaths) were reviewed as part of the inspection. Six resident’s care records and care plans were inspected. Most of the environment was checked and the only areas that were not seen were a small number of bedrooms. Sue Fuller, the Commission Pharmacist Inspector for the Bristol area, carried out an inspection of medication standards in the Home. What the service does well: Residents’ needs are generally being well met by the staff team. The staff team have built up close relationships with residents. Four Seasons and the Home have done a lot of work to review and improve the overall quality of care in the Home and the delivery of service to residents. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 6 Safe procedures are in place for storage, administration and disposal of medicines. Residents’ live in a Home that is being well run. Mrs. D’eath provides effective leadership to the staff, who are supportive of her. Residents are provided with a nutritious diet. A range of low-key social activities and entertainments are put on for residents. The design of the Home, and the adaptations in place make the environment generally suitable for the needs of residents. What has improved since the last inspection? The Home now generally demonstrates it can meet resident’s needs. This was evidenced by observing residents being cared for by staff , by talking to residents and their families , and by reviewing care records. Registered nurses are now keeping accurate records of the nursing care provided to residents. Additional medicine storage has been provided so that medicines can be stored securely on the floor they are needed. Records for medicines needing extra security and disposal records for unused medicines have improved. This shows that medicines have been looked after safely. Additional devices for blood testing have been obtained so that each person needing one has their own device. This helps to avoid the risk of infection. Seven new care staff and a registered nurse have been recruited .We met some of the new staff, who showed an enthusiasm and a commitment to caring for older people. Call bells in bedrooms (used by residents to ring for assistance) are now available and in easy reach of residents. The staff directly involved in caring for residents have now gone on training courses to help them understand the principal of the protection of vulnerable adults. The emergency lights on the top floor have been repaired and work properly in an emergency. Male residents who may need a protective apron when eating their meals are now being provided with an apron that is suitable for them. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 7 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 DS0000020249.V358803.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6.Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed however the needs of one resident admitted in an emergency had not been fully assessed. People can get the information they need to make an informed choice about living at the Home. Residents are provided with a statement of terms and conditions that set out the service, and what they will pay for it. Residents are not provided with intermediate care at the Home. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 10 EVIDENCE: To check on the quality and level of information there is available about the Home, a copy of the service users guide and statement of purpose were read. There are copies of the service users guide, and the statement of purpose in the hallway of the Home so that people have easy access to information about the Home. The complaints procedure is in the service users guide so that residents know how to complain about the service. The guide includes a photograph of the Home and surroundings. The statement of purpose includes information about the service provided, the qualifications of the staff employed, and the accommodation. The philosophy of the Home and how the service aim to meet residents needs is included. A copy of the statement of purpose is kept in the entrance to the Home and copies are also given to people on request. The philosophy of the Home is also on display on each floor, and is called the ‘ethos of care’. Three resident’s terms and conditions for staying in Home were checked. These are completed when residents are admitted. The terms and conditions include the fees charged, and the conditions that will apply while living at the Home. Each resident’s copy of their terms and conditions had been signed by them to show they had read and understood what was in them. Six peoples assessment records were read to find out how well their needs are assessed. There were completed assessments in place for five of the six residents. These records demonstrated an assessment of each persons needs, mobility needs, continence needs, risk of falling, mobility needs, and their skin vulnerability and the risk of pressure sores had been done. The assessment records were informative, and showed the residents range of physical, mental and social needs had been assessed. However one resident’s assessment did not reflect their full range of needs. The persons had been admitted in an emergency. There was some information to demonstrate the registered nurse had assessed some of the person’s needs. However there was a lack of information to demonstrate a full assessment of the persons needs at night, and their risk of falling at night had been carried out. There are no residents receiving intermediate care at the Home. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. Mostly residents’ care plans adequately demonstrate how needs are met. Residents’ needs are being met, and care plans now support how to meet resident’s needs. Medicines are looked after safely to protect residents’ health. Residents feel they are treated well by the staff and their privacy is maintained. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 12 EVIDENCE: Six residents care plans were read to see how effectively residents care needs are met. The care plans contained information to show how to meet the residents’ physical, psychological social, communication and needs. Since the last inspection the registered nurses have gone on care planning training run by Four Seasons trainers. This is to help the registered nurses to be able to write clear, and effective care plans. The quality of information in the care plans seen had improved since the last inspection. Information was clearer and generally easier to follow. One resident whose needs have already been mentioned did not have a completed assessment of their needs. Specifically their safety needs at night and the risk of the person falling at night. This has an impact on the information in the persons care plan as there was no information in the care plan about how to maintain the persons safety at night and how to minimize the risk of falls at night. The care plans seen had been reviewed and updated regularly. This shows residents’ needs are monitored and reviewed. Staff said that, at present, they look after all the medicines because none of the people living in the home are able to look after their own medicines. A selfmedication policy is available to make sure that if people are able to look after their own medicines, they can do this safely. A local pharmacy supplies medicines using a monthly monitored dosage blister pack system. A small number of homely remedies are kept for treating minor ailments and these have been agreed with the doctors looking after people living in the home. Since the last inspection, several new medicine cupboards and fridges have been purchased so that medicines can be kept safely on each floor of the home. Daily records are kept of the temperatures of the medicines fridges and these were all in the safe range for medicine storage. Suitable storage is available for medicines needing extra security. The registers used to record these medicines showed that they had been looked after safely. Since the last inspection, systems have been put in place so that staff can check that medicines supplied in standard packs have been given correctly. A sample of these medicines and a check of those supplied in blister packs showed that they had been given as recorded. Regular stock checks by staff have also been put in place to help to make sure that all medicines are given as prescribed by the doctor. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 13 We saw lunchtime medicines being given by staff on two floors. These followed good practice to make sure medicines are given correctly. The pharmacy provides printed medicines administration record sheets each month. Handwritten additions to these, for new medicines, were written in full, signed and dated and also checked by a second member of staff to reduce the risk of mistakes being made. Where medicines have been prescribed with a variable dose the amount given has been recorded on the medicines administration record sheet. Some people have been prescribed medicines to be taken When required. Separate sheets are kept with the medicines administration record sheets to give additional information to staff to make sure these medicines are given correctly. Some action is needed to make sure that these are kept up to date and include the reason the medicine is given. Records are kept of the receipt of medicines into the home. Records are also kept of the disposal of unused medicines. This means that there is a clear audit trail of medicines received, administered and disposed of by staff. Additional devices for blood sugar testing have been obtained so that people needing one have their own device. This helps to avoid the risk of infection. Many residents spoke very positively about how they feel staff help them to meet their needs examples of comments made by residents included, `the staff are very good ’, `oh yes they look after me very well ’, and, `I can’t grumble at all ’. Staff were seen assisting the residents all floors of the Home in a patient and unrushed way .The staff themselves said they felt they were able to give better care to the residents since there had been an increase in the number of care staff on duty on day shifts. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents are provided with a well balanced diet. However some residents are not satisfied with the quality of the food served. Residents can exercise some choices in their daily lives. Residents can take a part in a range of social activities. Residents are supported to receive visits from family and friends. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 15 EVIDENCE: Residents can take part in different low-key social and therapeutic activities that are put on by the full time activities co-ordinator. There is now a timetable of social activities planned to take place on display in the entrance hall. This helps the residents who see the timetable to be aware of activities that will take place. Activities that are planned for the near future include, arts and crafts sessions, games, a visit from a therapeutic dog, and musical afternoons. There were art works made by residents on display in the Home. A number of residents received visits from their family and friends during the inspection. Visitors said that the staff are welcoming and friendly. Residents were observed having cups of tea and coffee with their visitors. The Home has a relaxed and flexible visiting policy. This helps residents keep in contact with family and friends. The menu was reviewed to see what range of meals choices residents are offered. The Home operates a four-week flexible menu. The menu choices were varied and there was range of traditional meals provided. The acting manager has encouraged the staff to make sure they offer residents a choice of what meal they would like to be served in advance of mealtimes. This is a good way for residents to make choices in their daily lives. Staff were heard talking to residents and asking them if they wanted to be held to get up in the morning, staff were also seen asking residents where they wanted to sit in the lounge. These are also examples of residents being able to have some choices in their daily lives. The lunchtime meal was observed being served on two floors of the Home. The meal choices consisted of baked gammon, sausages, and cooked vegetables and potatoes. The meals were adequately tasty. Some of the residents we met said that they thought the food served to them was ‘ good ’, and ‘ tasty ’. However a number of residents commented negatively about the quality of the meals that are provided. Comments made included, ‘ the food’s not very nice ’, ‘ the food varies ’, and ‘ it’s awful ’. Care staff were working hard serving food to residents in their rooms, and in the dining rooms. Residents needing extra help with their meals were being helped in a discrete way by staff who sat down by them. This helps keep the person’s dignity and make the mealtime more personal for residents. Kingswood Court DS0000020249.V358803.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. Residents are now better protected from abuse by staff training and procedures. Residents’ complaints about the service are responded to thoroughly. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 17 EVIDENCE: There is a copy of the complaints procedure on display on each floor. Residents are given their own copy of the complaints procedure with the service users guide. This helps residents and their representatives to get hold of the information they need to be able to complain. The complaints procedure includes the up to date contact information for the Commission if a person wants to contact us directly. A complaints file is now kept on each floor of the Home. This is so that residents can make their complaints known to the staff. The acting manager monitors and investigates the complaints received. Since the last inspection there have been four complaints made to the Home. Two of those complaints relate to allegedly poor care practise, and the complaints had been thoroughly investigated by the acting manager. Residents and staff said that they see the acting manager regularly. They said that she meets with residents if they have any concerns or complaints to try and resolve them. Since the last inspection the acting manager has put in place a staff training programme on the subject of abuse. The acting manager has done her own training and she specialises in training in this subject. The majority of the staff team have now done this training run by the acting manager in the understanding of the principle of the protection of vulnerable adults from abuse. The staff spoke knowledgably about the subject of abuse and how they protect residents in the Home. There is a `protection of vulnerable adults’ policy to help to guide staff to take the correct course of action if they ever have to respond to an allegation of abuse. Kingswood Court DS0000020249.V358803.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 adequate. This judgement has been made using available evidence including a visit to this service. The Home is clean and mostly satisfactorily maintained . Improvement are being made to the environment so that it is more suited for the needs of the residents . Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 19 EVIDENCE: A programme of redecoration, and updating of the Home has now begun. Painters were painting communal areas. There were also builders upgrading the showers and bathrooms on the first and second floor of the Home. As was quoted in the last inspection report and is still applicable ‘Kingswood Court Care Home is a large property that was built to be a Nursing Home. It is situated in Kingswood, near Bristol. The Home is built over three floors that can be reached by stairs or lift. The building is a twenty-minute car ride away from Bristol City Centre. There are local shops, a library, a church, pub and Cossham Hospital nearby’. The environment was clean and satisfactorily maintained throughout. However there is an area of tiles on the kitchen wall that should be deep cleaned, as there is grease between the tiles. Since the last inspection the emergency lights on the top floor have been repaired and now work properly in an emergency. There is a range of specialist equipment and adaptations in place throughout the Home, to assist people with reduced mobility. The majority of bedrooms are for single use, however there are two double rooms. Rooms were adequately decorated and maintained. Workers were seen painting bedrooms, and the ground floor lounge. All bedrooms have en suite facilities, and there are bathrooms and toilets located close to living rooms. There are suitable adaptations in toilets and bathroom to assist people who have reduced mobility. There is also lift access to the first and second floor ’. There are three open plan dining and television lounges. These rooms looked light and spacious. Residents were observed sitting in communal areas and looking comfortable in their surroundings. The domestic staff were observed working hard cleaning the home. It was also good to see the domestic staff talking to residents in a very friendly, warm way. Kingswood Court DS0000020249.V358803.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’ needs are being met by a sufficient number of competent staff. Residents are being cared for by staff who are trained to do their jobs. Residents are protected by the Homes recruitment procedures. EVIDENCE: The number of staff on duty was reviewed to find out if there are enough staff to meet residents’ needs. The staff duty record for nursing and care staff for the previous two-week period was checked. This was done to find out if residents are cared for by enough staff to ensure needs are met. For the current number of 56 residents there is a minimum of three registered nurses and nine care staff on duty every morning shift. There are three registered nurses and seven care staff on an afternoon shift, and two registered nurses and five staff on duty at night. Since the last inspection the numbers of staff have been increased. On each day shift there is now an extra care assistant. The increase in staff on duty has had a positive impact on residents and how their needs are met. Staff told us that they felt they had more time to spend caring for residents. Staff were observed sitting in residents rooms talking to residents in a warm and friendly way. Where possible the Home tries to cover any shortages with their own staff. However there has been some use of agency staff as well. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 21 There are domestic staff on duty each day, a cook and kitchen assistants, a full time maintenance person, and an administrator. The acting manager is full time and works a range of different hours, to fit in with the needs of the Home. The staff were observed assisting residents with their care needs in a courteous and patient manner. The increase of one extra care assistant on duty for each morning and afternoon shift has had a positive impact on residents. This was seen when care staff were observed being able to spend more time talking to residents, and also having more time to spend helping residents with personal care needs. The staff also said that they feel they have been able to provide a better service to residents with the additional staff on duty. A new staff structure has been introduced to improve the quality of the service to residents. There is now a senior care assistant on duty for every day shift to provide additional leadership, to support the registered nurses. We met three senior care staff, and they conveyed that they have a good understanding of what their role is and how they must monitor the quality of care and support the registered nurses. The training records of the staff team were looked at to see if staff are keeping up to date in their knowledge of the needs of residents. The acting manager has worked hard since the last inspection to motivate staff to go on a range of training and updating courses. Registered nurses have recently done ‘wound care ’ training, care-planning training, and leadership training. There was good evidence that staff had attended training sessions, and updating over the last twelve months. The acting manager is booking staff onto with National Vocational Qualification in care awards to Level 2 or Level 3. This is good evidence that demonstrates a commitment by the care staff to developing the skills that they have. The staff recruitment records of four recently recruited staff were checked to see if the Home carries out the required employment safety checks on staff before they start work. There are two written references taken up for all new staff before they start work as well as Criminal Records Bureau Disclosures checks and Protection of Vulnerable Adult (POVA) first checks. This demonstrates residents are protected by the Homes recruitment procedures. Kingswood Court DS0000020249.V358803.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): 31,33,37,38.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The acting manager is running the Home for the benefit of residents and the staff. The care residents receive has improved because there are effective systems in place to monitor the quality of the service in the Home. Residents are protected by the health and safety practises and procedures in place. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 23 EVIDENCE: Mrs. Linda D’eath has been appointed as the acting temporary manager. She is in the process of applying to us to be the registered manager. Staff spoke positively of Mrs. D’eath. Staff said they felt Mrs D’eath was approachable, and listened to their concerns. Staff were also observed approaching Mrs. D’eath and communicating well with her .She has considerable experience in running Care Homes, and in teaching and management at a National level. Mrs. D’eath has moved her office from the middle floor to the ground floor. This has had an impact on the running of the Home as it means that residents, relatives and staff can see her even more readily then before. A senior manager has been visiting the Home on a weekly basis to check on the overall quality of care and service. The acting manager said that the senior manager would walk around the Home, talk to staff and residents and observe what is going on. During the inspection a senior clinical manager came to the Home to carry out audit of the quality of the care plans and their suitability to meet residents needs. The acting manager said that having regular audits and review of the home has been very helpful in ‘driving up’ standards. The monthly monitoring visits of the Home that must be carried out by a representative of Fours Seasons are being undertaken as required by law. There are records of these visits. Records are held securely in locked filing cabinets that are locked when not in use to maintain confidentiality. Records were satisfactorily maintained. Other records have been referenced elsewhere in the report. The environment looked safe and satisfactorily maintained. A full time maintenance worker is employed who was observed carrying out maintenance and repair work. The staff team are in the process of doing a range of health and safety training courses. This is beneficial so that staff keep up to date in their knowledge of health and safety practices. In February 2007 kitchen staff at the Home won the local environmental health food safety award. This award helps to demonstrate kitchen staff are following good health and safety practices and procedures in food safety. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 24 The fire logbook record confirmed the required fire tests and checks are being carried out and are up to date. This helps to maintain the safety of everyone in the Home. Staff have done fire safety training in the last twelve months. This training helps staff know what to do in the event of a fire. A sample of resident’s accident records for January 2008 were looked at. The accident records showed registered nurses record in detail the nature of the occurrence, and all follow up action over a period of days after the event. To further protect the health and safety of residents the acting manager and a health and safety manager audit and monitor all residents and staff accident records. Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 X 3 X X X 3 3 Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 26 NO 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 OP3 Regulation 14 Requirement All new residents must have an assessment of their needs carried out. This requirement relates to the need for residents admitted in an emergency to have a full assessment carried out so that the Home know it can meets the persons needs. Timescale for action 06/02/08 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 OP15 Good Practice Recommendations Review the quality of meals provided to residents, and DS0000020249.V358803.R01.S.doc Version 5.2 Page 27 Kingswood Court 3. OP9 seek the views of residents when doing this. Information sheets about medicines prescribed, When required need to be kept up to date and include the reason for the medicine being given. Deep clean the tiles on the kitchen wall. This relates to one part of the wall that needs further cleaning. 2 OP26 Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kingswood Court DS0000020249.V358803.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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