Inspection on 22/10/07 for Kingswood Lodge

This inspection was carried out on 22nd October 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 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 Lodge 07/03/07

Kingswood Lodge 07/11/05

Kingswood Lodge 01/07/05

Kingswood Lodge 28/02/05

Kingswood Lodge 12/05/04

Similar services:

London Road Neurological and Specialist Care Unit

Carlton Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Kingswood Lodge Long Street Wigston Leicestershire LE18 2BP Lead Inspector Keith Williamson Key Unannounced Inspection 22nd October 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kingswood Lodge DS0000001738.V348697.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 Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingswood Lodge Address Long Street Wigston Leicestershire LE18 2BP 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) 0116 2812582 0116 2884236 Mr David William Barnacle Mrs Janet Barnacle Mrs Jane Adkin Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 7th March 2007 Brief Description of the Service: Kingswood Lodge is registered to provide personal care and accommodation for up to twenty-one older people. The home is situated close to Wigston town centre near shops, pubs, library and other amenities and accessible via public transport. Car parking is available to the front of the home. The home is a large converted property with en-suite bedrooms over two floors. The home has level entry access to the front and rear of the home. Bedrooms on the first floor are accessible via the stairs or the passenger lift. There are sufficient number of toilets, bathrooms and washing facilities. Service users have the option of three lounges on the ground floor, of which one looks on to the landscaped garden to the rear. The Statement of Purpose, which sets out the latest aims, objectives and philosophy of the home, about its services, facilities, and current staffing, is located on site detailing the range of services offered, which includes the Service User Guide or brochure. Copies of the last Inspection report is located on a table in the foyer. The weekly fee charged falls between £327.00 and £388.00. There are additional costs for individual expenditure such as dry cleaning, telephone, personal toiletries, social outings, opticians and dental charges and the fee will depend on the services received. Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections is on outcomes for Service Users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting a sample number of clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation, in this case three Service Users were chosen. This inspection took place over one day, commencing at 9.20am and took six and one half hours to complete. One inspector conducted the inspection (or site visit). An opportunity was taken to look around the home, view records, policies and care plans and to talk to Service Users and staff. Information was gathered prior to the site visit from sources such as Service Users, their relatives and staff comment cards; the pre inspection questionnaire from the acting manager and in some cases complaint information. Twelve of Service Users were seen and six spoken with during the inspection process, some of the comments made, are included in this report. No comment cards were returned prior to the completion of the inspection visit. What the service does well: Service Users are supported and encouraged to make choices and continue to enjoy their preferred lifestyle. Service Users have individual plans of care and daily records and care staff demonstrated a good awareness of the people they care for, knowing individual care plan outcomes. The Service Users are offered a range of religious, social and leisure activities both within the home and outside. Visitors are welcome at the home at any time. Residents spoken with and comment cards received from residents, all stated that the meals were good. The home is clean and well maintained; all Service Users have locks to their bedroom doors. Throughout the home, the décor creates a homely and relaxed atmosphere. Service Users have a choice of lounges where they can relax including a designated smoking lounge. Kingswood Lodge is well-managed care home that provides care that is tailored to the individual people. Staff files and training is up to date, and staff supervision is in place, and performed regularly. Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 6 Service Users monies held by the home, were up to date and accurate. Staff have a good awareness of the complaints procedure and vulnerable adults and whistleblowing strategies. Safety checks for health and safety purposes are in place, and performed regularly. Staff are well thought of, and Service Users stated “the staff are nice and friendly” and “they sit and have a chat with us now and again”, and of the meals “the meals are good” and “the food is very good”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kingswood Lodge DS0000001738.V348697.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 Lodge DS0000001738.V348697.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): 1, 2, 3, & 6. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The assessment process for Service Users is detailed and effective; however changes to the terms and conditions of the Service Users stay would help to make the process more secure. EVIDENCE: There is a Statement of Purpose, which sets out the latest aims, objectives and philosophy of the home, about its services, facilities, and current staffing. This document needs to be updated; the Registered Manager stated she planned to do this in the near future. Service Users have individual contacts, which set out the terms and conditions of residency, though this document requires to be updated to reflect the current registering authority. Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 9 The Registered Manager confirmed that Service Users are assessed prior to admission. Service Users spoken with confirmed satisfaction with their own experiences of the admission processes, having had adequate information provided about the home and opportunities to visit prior to deciding whether they would like to live there. The home does not offer intermediate care. Kingswood Lodge DS0000001738.V348697.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. Service Users physical health and personal care is managed appropriately, however social care could be more detailed in care plans. EVIDENCE: All of the Service Users case tracked had appropriately developed plans of care and there was evidence that these are regularly reviewed and wherever possible involved the Service User or their representative. Care plans give staff instruction on how to complete Service Users physical needs and there is evidence to demonstrate that that care was being delivered according to the individual plans of care. Social and emotional care is not well detailed in care plans, or recorded in daily records, however Service Users indicated a number enjoy activities with the staff, a recent film day being a Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 11 topic of conversation. Key workers and other staff demonstrated a good understanding of the Service Users’ care needs. Service Users have yet to have nutritional assessments completed by staff, as there was no evidence that this had been attempted. Medication systems are managed well; all the medication administration records were found to be in good order, with no missing signatures or omissions. Short course medications such as eye and ear drops are appropriately dated, and disposed off properly at the end of the courses. The medication trolley is currently stored in the office and some thought should be given to fixing this to the wall. The registered manager confirmed that Service Users who chose to self medicate shall have appropriate risk assessments conducted. There was evidence that the privacy and dignity of Service Users was respected at all times. Staff were seen to relate well to Service Users, to knock and wait for permission to enter their private accommodation. Service Users confirmed that personal care and consultations with medical staff were conducted in private. In general Service Users confirmed that staff them treated them well and that they were well cared for, one Service User stating, “the staff are nice and friendly” and “they sit and have a chat with us now and again”. Kingswood Lodge DS0000001738.V348697.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 & 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service Users continue to make choices about daily living and are offered a variety of meals and social activities of interest. EVIDENCE: Social and recreation care has is provided for the majority of residents in the home, though recording of social events are not consistently recorded on Service Users’ files. Menu records showed that a good range of “traditional English” food is served reflecting the cultural heritage of the Service User group. Dietary needs and preferences are recorded in care plans and discussion with Service Users suggested that these were accurately recorded. Many positive comments were received about the food “the meals are good” and “the food is very good”. Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 13 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. Service Users are protected by an accessible complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: The complaints policy and procedure have now been amended, and these are still available in the foyer of the home. The complaints records were viewed with no further complaints being recorded since the Inspectors last visit, and no complaints being made to the Commission for Social Care Inspection. Service Users stated they were happy to speak with the staff or registered manager if they had any concerns regarding the home. Staff showed a good awareness of whistleblowing and adult protection strategies. The inspector was made aware of a concern prior to the visit commencing; this had been acted on appropriately, and investigated in line with the local Adult Protection Policy. Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 14 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, 22 & 26. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service Users live in a homely, comfortable and clean environment. EVIDENCE: A number of improvements have been made in the home with carpets being replaced throughout the home; and dining chairs being replaced. However there is no ongoing plan of refurbishment for the home to enable the tracking of the improvements and the timescales involved. Residents’ personal bedroom space, and public areas of the home were pleasantly decorated, though the paintwork to the corridors requires some attention, following damage by wheelchairs. Adaptations and specialist Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 15 equipment such as hoists and raised toilet seats were seen in place throughout the home. Staff showed and awareness of cross contamination and cross infection issues. However, the laundry area requires some attention to ensure that surfaces are made free from water penetration, to ensure Service User and staff safety Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 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 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. The numbers of staff and improved recruitment process ensures Service User safety in the home. EVIDENCE: There are currently no built in “handover” times for staff, therefore staff commence there shift early or go off late to enable information to be passed to staff commencing duties. Care staff are employed in sufficient numbers to enable personal care tasks to be undertaken. Kingswood Lodge has 65 of the staff trained to National Vocational Qualification in Care, level 2 or above. Eleven staff holds current first aid certificates and five staff have received training in ‘safe handling and administration of medication’. Staff training records kept in individual books showed the training completed by the staff and the date. The recruitment process has improved with all staff files sampled having the appropriate references and Criminal Records Bureaux checks in place. Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 17 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, 36 & 38. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management approach promotes effective care practice in the home for Service Users care and protection EVIDENCE: The registered manager has many years experience of working and managing Kingswood Lodge, and qualified having passed the Registered Managers award. The registered manager is aware of the categories under which Service Users can be admitted into the home. Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 18 Quality assurance questionnaires have been distributed to Service Users and their relatives, though not since the last visit to the home. No quality assurance information has been added to the Service User Guide. Resident finances are kept appropriately; of two records seen both were up to date and accurate. Staff supervision is currently undertaken in the home. Staff spoken with confirmed the “one to one” meetings. A sample of accident reports was completed appropriately, and there is accuracy between these and the Service Users individual daily records. Fire records including the weekly fire alarm tests, emergency lighting tests, and the servicing of fire appliances were all found to be up to date. The fire risk assessment was also seen this has also been updated. Other records viewed included the record of hot water tests in the home Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 19 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 2 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 2 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 2 X 3 3 X 3 Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP26 Regulation 13 (4) a Requirement The Registered Person must ensure that all surfaces in the laundry are non permeable. This would ensure the possibilities of cross contamination and cross infection are kept to a minimum. The Registered Person shall visit the care home at least once a month; Seek the views of the Service Users and their representatives, staff, inspect the premises and check the record of events and compliance and prepare a written report on the conduct of the care home. This would ensure the Responsible Individual oversaw continued development of the home. (This requirement with an original timescale for action of 07/04/07 remains unmet). Timescale for action 12/12/07 2 OP33 26 12/12/07 Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 21 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 2 Refer to Standard OP9 OP19 Good Practice Recommendations The Registered Person should ensure that the medication trolley in office is chained or secured to wall. The Registered Person should ensure that a plan of refurbishment and replacement of furniture and fittings is produced and updated on the completion of work. The Registered Person should ensure that record or log in kept detailing the Criminal Records Bureau disclosure number for all staff working at the home and made available. 3 OP29 Kingswood Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Lodge DS0000001738.V348697.R01.S.doc Version 5.2 Page 23 - 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. 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