Inspection on 06/09/05 for Kingswood Lodge

This inspection was carried out on 6th September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kingswood Lodge 30/01/09

Kingswood Lodge 08/09/08

Kingswood Lodge 22/11/07

Kingswood Lodge 16/03/07

Kingswood Lodge 14/02/06

Kingswood Lodge 02/04/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Kingswood Lodge 25 Railway Street Gillingham Kent ME7 1XH Lead Inspector Anne Butts Announced 06 September 2005 10:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Kingswood Lodge Address 25 Railway Street Gillingham Kent ME7 1XH 01634 580797 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) Doson Limited Mrs Delores Celene Lee Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Eighteen (18) People with Learning Disabilities, One (1) of which will have a Physical Disability. Date of last inspection 02 February 2005 Brief Description of the Service: Kingswood Lodge is located in the centre of Gillingham and is close to the main railway station and other local transport. It is a short walk from the high street and other amentities. There is car parking to the rear of the property and the garden is attractively laid out with raised flowerbeds, a lawn and seating area. The home provides accommodation on three floors with sixteen single rooms and one shared room. There is a lift to the first floor. There is a games room and a choice of sitting rooms. There is a spacious dining area with a conservatory attached. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which was carried out by two inspectors. During the course of the inspection a tour of the premises was undertaken, service users and staff were spoken to and records were viewed. The inspectors were supported by the owner and the manager throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: There are areas of the home that are still in need of redecoration, and some furnishings need to be made good and an odour can still be detected in parts of the home. There is still a need to ensure that all service users benefit from having appropriate bedding. Although record keeping was generally good reviews that are held with service users are not recorded and medication reviews need to be addressed. Risk assessments need to be improved so that actions for outcomes clearly address how staff meets the service users individual needs. Current and prospective service users would benefit from the Statement of Purpose and Service Users guide being made available in a user friendlier format. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 6 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 Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 and 4 Service Users and representatives are given all the information that they need to be able to make an informed decision about living in the home. Service users benefit from an assessment process that ensures objectives and outcomes are promoted. EVIDENCE: The home’s Statement of Purpose and Service Users Guide are informative documents and contain all the information as required. They would benefit, however, from being made available in a user-friendlier format using more pictorial and photographic references suitable for the people for whom the home is intended. Care plans viewed contained full assessments for service users and included risk assessments and specialist health assessments. Assessed needs identify individual incorporated into care plans. objectives and outcomes and are The home’s admissions procedure sets out how service users are encouraged to visit prior to admission and have an opportunity to meet other service users. The registered provider also confirmed that prospective service users are invited to spend time in the home including being invited for meals. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 9 Contracts are in place for service users with all the required information. The home promotes the use of advocates for those who may need to access this service. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8, and 9. Service users benefit from comprehensive care plans which are aimed at supporting them in meeting individual needs. However their safety may be put at risk, as the care plans are not supported by risk assessments that address how to fully support service users in meeting their needs. EVIDENCE: Care plans were viewed and contained detailed information from Care Management and the home’s individual assessments on how to meet the needs of the service user. Care plans contained a personal profile for each service user so allowing for staff to have an awareness of the background and individuality of the service user. They evidenced that carers and family are involved in the care planning process and the Statement of Purpose and Service Users Guide reflect service users rights to make their own decisions. One service user spoken to on the day described how he was able to choose what he wanted to do and the work he was doing in a local charity shop. The home has regular service user meetings and records evidenced that outcomes are recorded and acted upon. There is risk taking agreements in place and where bed rails needed to be put in place for service user safety records evidenced that this had been agreed with the individual – so promoting service user participation in their own care needs. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 11 There are individual risk assessments for all aspects of lifestyle and these are aimed at supporting and promoting service users to be able to be as independent as possible. However, although the assessments are aimed at outcomes there were no guidelines or procedures recorded of action to be taken by staff in order to meet these outcomes – it was recommended that as care plans are reviewed risk assessments be completed thoroughly ensuring that actions to be taken are included. The home has in place procedures and comprehensive documentation for the recording of reviews – in the care plans viewed, though, not all of these have been completed and it was also recommended that these are completed so as to ensure that any changing needs are identified and met. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 16 and 17. Service users benefit from being able to make choices and decisions about their daily lives. EVIDENCE: Five service users were spoken to. Feedback was positive regarding the home, social activities and choices. Service Users said they could get up and go to bed when they liked. They liked the food and could have different things if they wanted. They were encouraged to help in the kitchen. Service Users also confirmed that they had regular holidays and that the home has a minibus for their benefit. Independence is encouraged with service users being encouraged to access the community independently. Service users have access to adult education evening clubs and one service user has a part time voluntary job. Transport is not currently accessible for wheelchair users and a requirement/strong recommendation should be made to ensure that all service users community access needs can be met. Overall service users spoke positively about staff saying they are nice to us, I like them. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 13 The home has a ‘games’ room that all service users can access and there is a wide variety of activities to choose from. Menus were viewed, and although an alternative is not listed on the actual menu the Manager stated that choices are available and service users request if they prefer something different to the offered meal. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Health needs are met and service users have full access to all professional health care services as required. The service users’ welfare was protected by the home’s policy and procedures with regard to the handling and administration of medication; however, inappropriate storage of some medications could place service users at risk. EVIDENCE: Care plans included how service users are supported with their personal needs by staff and evidenced that their choices and preferences are taken into account. Records also showed that service users are able to access G.P.’s and other health professionals as required. Medication was being recorded accurately and certificates seen and discussion with staff evidenced that staff who administer medication have undergone appropriate training. It was noted that some medicines were inappropriately stored in the kitchens fridge. A requirement has been made that the home should purchase a lockable medication fridge and that where necessary medicines are dated once opened and discarded when out of date. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 15 It was also noted that some service users did not appear to be having regular medication reviews and a requirement has been made that these should be sort and that the outcomes recorded. As discussed a specialist referral should be sort for the service user identified. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Service users can be confident that their complaints will be dealt with effectively through the home’s clear complaints system. Robust adult protection policies and procedures and staff who are trained protect service users. EVIDENCE: There is a comprehensive complaints procedure in place which meets all the requirements of this standard with appropriate time scales and how and whom the complaints can be made. Records evidenced that any complaints were taken seriously and appropriate action taken and fully recorded with outcomes. There are policies and procedures in place to promote good practice including a Whistle Blowing Procedure and Adult Protection and Prevention of Abuse Procedure. Staff are given procedures at induction and they are re-iterated at staff meetings. The registered manager is also a trainer in Adult Protection protocols and all staff have completed their training for this. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28, 29 and 30 Whilst the majority of service users benefit from living in a safe, clean and comfortable environment, some areas of the home are not odour free and are in need of refurbishment EVIDENCE: The property is situated close to the town centre and has good access to local amenities and transport. The home also operates a minibus that is used for the benefit of service users. The home now has sixteen single rooms and one double room, and all rooms are of an appropriate size for the needs of the service users including one room that meets the needs of an individual whose mobility is limited. The inspectors undertook a tour of the premises and several rooms were viewed – these all showed evidence of service users individuality and own belongings and contained furniture and fittings as identified within the standards. Since the last inspection some mattresses and pillows have been replaced and some appropriate mattress protectors have been purchased, however there is still a need to ensure that all service users have the benefit of appropriate bedding and a requirement has been made to this effect. It was Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 18 also noted that some of the rooms would benefit from being redecorated or having chairs re-upholstered in particular the coverings for the chair in room eight was torn and needed replacing and room six was in need of redecoration. Some wardrobes were seen to be unsafe in that there was a possibility that they may topple over – it was recommended these were made safe. The home has recently had an Occupational Therapist assessment carried out with regards to any aids and adaptations that are needed to support services users who are less mobile. An action plan has been put into place to address any recommendations and requirements made from this report. There is a lift to the first floor, a mobile hoist and wheel chairs and Zimmer frames are provided as appropriate. Overall the home is reasonably decorated and clean and hygienic although there are some areas in which an odour can be detected and it was recommended that this be addressed. Other areas that would benefit from improvement included the laundry, which is in need of new flooring and the walls need to easily cleanable finish. Some parts of the home have benefited from refurbishment and redecoration including the bathroom on the top floor. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 Service users can be confident that trained and competent staff meet their care and support needs. EVIDENCE: Records viewed showed that staff have undergone all mandatory training and there is a full training programme in place for future needs. In addition training has been put into place to meet the specific needs of this service user group. Several members of staff have completed their NVQ level 2 with others part way through the course – the home is on target for any required timescales with regards to this. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39,40 and 42 Quality management systems ensure that service users views and opinions are listened to and acted upon. Service users can be confident that the home’s policies and procedures protect their interests. EVIDENCE: The home has good quality management systems in place that includes questionnaires for service users and relatives, meetings are held with service users with recorded outcomes and action taken following these meetings. The owner and the registered manager are clearly committed to listening to the service users needs and acting upon them. A sample of policies and procedures were viewed and they are appropriate for the home and are reviewed regularly. Staff are issued with a handbook which has a summary of all policies and procedures which they sign for. These are also covered during the induction process and at staff meetings. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 21 Full health and safety risk assessments are carried out, although it was recommended that these be reviewed on a regular basis and dated as such. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 3 2 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x 3 x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kingswood Lodge Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 3 x 3 x H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 23 Are there any outstanding requirements from the last inspection? No - although any outstanding have been met in part. 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. 2. Standard 6 20 Regulation 15 {2(b)} 13 (2) Requirement The service users plan must be kept under review and these reviews must be recorded. The Registered Person shall make arrangements for the recording, handling, safekeeping, safe administration and safe disposal of medicines received into the care home - in that a suitable lockable medication fridge is purchased for the safekeeping of medicines. Service users must have regular medication reviews with their GP which are recorded. The registered person must ensure that the home is free from offensive odours. The registered person must ensure that where necessary appropriate mattress protectors which have sufficient fabric covering to reduce the risk of sweating are in place. The registered person must ensure so that to prevent the spread of infection that the laundry floor is replaced and is of an impermeable finish. Timescale for action On receipt of this report. 31st October 05 3. 4. 5. 20 24 26 13 {1(b)} 16 {2(k)} 16 {2} On receipt of this report. 31st October 05 31st October 05 6. 30 13 {3} 31st October 05 Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 1 9 24 24 42 Good Practice Recommendations It is recommended that the Statement of Purpose and Service Users Guide are made available in a user friendlier format to meet the needs of the service users group. It is strongly recommended that risk assessments have actions to be taken by staff on how to meet individual service users needs. It is strongly recommended that any areas of the home which are in need of redecoration are addressed, and furniture is repaired as identified within this report. It is recommended that wardrobes are made safe. It is strongly recommended that health and safety risk assessments are reviewed and review dates are recorded. Kingswood Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 Lodge H56-H06 S28918 Kingswood Lodge V239187 060905 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!