Inspection on 07/03/07 for Kingswood Lodge

This inspection was carried out on 7th March 2007.

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

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

Other inspections for this house

Kingswood Lodge 22/10/07

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 Rajshree Mistry Key Unannounced Inspection 09:20 7th March 2007 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.V329965.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.V329965.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.V329965.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 November 2005 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 property converted 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 is a designated smoking lounge that looks on to the landscaped garden to the rear. The home is clean, safe and comfortable with a bright, cheerful, décor. The staff are committed, cheerful and have a good relationship with each other and the service users. Staff training is provided on a regular basis with a large proportion of staff completing various levels of the National Vocational Qualification awards. Information is located on site detailing the range of services offered, which includes the Statement of Purpose, in addition to this Kingswood Lodge has copies of the Commission of Social Care Inspections, Inspection Reports, which are located on a table in the foyer. The maximum weekly fee is £387.00, which was provided on the day of the Inspection. 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.V329965.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, which included viewing the previous Inspection Report and the service history that has details of any significant events affecting the wellbeing of the people living at the home. The pre-inspection questionnaire was sent out to Kingswood Lodge but not available in preparation for the site visit. Comment cards were sent out to residents and were not available in preparation for the site visit. The unannounced site visit commenced on the 7th March 2007 and lasted 1 day. The focus of the inspection is based upon the outcomes for the residents. The method of inspection was ‘case tracking’. This involved identifying residents with varying levels of care needs and looking at how these are being met by the staff at Kingswood Lodge. Four residents were selected and some discussions were held with residents and observations were made of other residents who were not part of the ‘case tracking’ process. The visiting General Practitioner and relatives had the opportunity to express their views about the home and care provided to the residents. The method of case tracking included the review of residents’ individual care records, discussions with staff of various delegated responsibilities within the home and reviewing the records, training records and the minutes of team meetings. The CSCI sent out Comment Cards to residents, of which 7 were returned, some completed by relatives on behalf of the residents. The comments received were generally complimentary and included: “The staff are always caring and supportive and never hesitate to call for a nurse or a doctor, if necessary” “Always invited to take part in any activity that has been arranged” “Very happy at Kingswood and the staff are wonderful” “Seems very fresh and downstairs clean, but bedrooms perhaps could do with some small maintenance jobs doing to improve appearance” “I have completed this form on behalf of . . . . . . . who is poorly. The care she is receiving from all the staff is superb. They always find time to talk to the family and keep us informed of our relatives progress”. What the service does well: Kingswood Lodge is well-managed care home that provides care that is tailored to the individual people. Residents are supported and encouraged to make choices and continue to enjoy their preferred lifestyle. Care staff demonstrated Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 6 a good awareness of the people they care for, from addressing them by the preferred names, knowing individual routines and preference of meals. The residents 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 comment cards received from residents all indicated a high level of satisfaction in the care provided by the home. The home is clean and well maintained. Throughout the home, the décor creates a homely and relaxed atmosphere. Residents have a choice of lounges where they can relax including a designated smoking lounge. 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.V329965.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.V329965.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 and 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed information is available as to the services offered by the home, and residents care needs are well assessed before they move into the home to ensure their needs can be met. EVIDENCE: Individuals considering residential care at Kingswood Lodge are provided with the home’s brochure, which has information referred to as ‘The Statement of Purpose’. The document provides a brief description of the services provided, including the accommodation, information as to the number of staff employed including information as to qualifications and training. The document also details the number of places provided and systems to measure the quality assurance process and complaints procedure. The Statement of Purpose is available upon request; a copy is on display at all times in the reception lounge. Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 9 The records of four residents were viewed, and all were found to contain a contract of stay, which outlines the terms and conditions of occupancy including information as to the fees. Where the local authority funds residents, a comprehensive assessment of the individuals needs is carried out by the Care Manager and produces a document to reflect their findings forms part of the referral process and confirmed with the ‘Individual Placement Agreement’. The Registered Manager upon receipt of the information carries out a further assessment to ensure that the staff at the home could meet the persons care needs safely and promptly. The assessment form contained written information of the residents care needs, history such as medication, mobility, special diets and meals, communication needs, mental wellbeing and social, religious and cultural needs. The admission process is good and involves the prospective resident and their relative or advocate. Three residents were spoken with regarding their involvement in choosing Kingswood Lodge, one lady said her family viewed the home and spoke with the staff and the Registered Manager to be satisfied that this was the right home. Whilst another resident said, she had chosen to move into to the home in order that she could remain in the local area and be close to her family. Comment cards received from residents indicated contracts and individual placement agreements were signed. Standard 6 is not applicable, as the Kingswood Lodge does not provide intermediate care. Kingswood Lodge DS0000001738.V329965.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well cared for having their tailored health and daily care needs met. EVIDENCE: The care plans and records of four residents, a newer resident. The care plans were well written and were presented to a good standard. The care plans were personal to the resident, setting out some history and background of the resident, the level of assistance required, specific dietary needs, observance of religious or spiritual practice and social interests including family. Care plans detailed information as to residents’ health care needs, daily living arrangements, which outline residents, preferred daily routine and the impact of cognitive skills such as mental health on the individual and the ability to do buttons or zips. Specific health care support provided by the Community Nurse were part of the care plan. Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 11 Risk assessments have been undertaken for all aspects of a resident’s health, which require monitoring to ensure health and well being, for example, falls, nutrition. This was reflected in the care plans detailing the risks and how these should be minimised and reflected the views and preferences of the resident. Residents told the Inspector that their individual needs were met by the staff and were comfortable here. The visiting relative said they had seen a great improvement in their mother’s wellbeing, and this was felt because of way the staff care for her. One resident not being case tracked said had been poorly with diarrhoea. Staff described the actions taken in early morning when the resident was seen to be ill. Information received from the resident and staff caring for the resident confirmed that appropriate measures were taken to protect him and others and that medical advice was sought from the General Practitioner. The resident said he was regularly seen by the care staff and encouraged to drink water. The Community Nurse had been to see a resident in the morning and left before the Inspector could speak with her. One resident was seen getting into an ambulance, which had been booked so that the resident could attend her appointment at the hospital. Health care records and daily records viewed for the residents tracked showed, staff were recording the purpose of the visit, treatment prescribed or instructions given to follow. The visiting General Practitioner confirmed he had no concerns about the people living at Kingswood Lodge and would not hesitate in choosing this home for himself. Residents spoken with said that they are seen by the GP if required, although do see the GP popping into the home before or after surgery. Staff were observed throughout the Inspection interacting with residents and responding to call bells, which rang occasionally. Residents were observed being assisted to the toilet and their bedrooms when asked. Comments received directly from residents included: “ . . . . . would speak with me if things changed with my health” (this is in relation to changes in the care planning) “The girls help me in and out of the bath, I sit in the chair which lifts me in and out of the bath and I’m always covered up with a towel” The medication is stored in a locked medication cabinet and stored in the office securely. The Registered Manager and Senior Carers have received training in ‘Safe Administration of Medication’. The management, receipt, storage and recording of medication are good. Senior carer described procedures followed to administer controlled medication; demonstrating practice is safe and well managed. Medication for residents tracked were checked against the medication records and found to be correct and up to date. Resident said they receive their medication on time. Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents continue to make choices about daily living and are offered a variety of meals and social activities of interest. EVIDENCE: The care plans viewed contained background information as to resident’s hobbies, interests, likes and dislikes. The daily records of residents recorded their involvement in activities, including visits by relatives and friends. Activities to which residents have participated in include, bingo, music and movement, sing along sessions and skittles. Residents described the types of chair exercises they do every fortnight and said how much they enjoyed the entertainers that visited the previous day. A resident said the Pentecostal Church visit regularly and does hymns and services. The Registered Manager booking for the Easter service has been with the same church. One resident said she enjoys going to the centre to purchase her own toiletries and to “window shop’ saying there’s nothing better than to shop for yourself”. One resident was seen doing a ‘word-search, whilst Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 13 another was reading a book, using a magnifying lens, and then telling the Inspector that she has a selection of books available. A member of staff specifically works Saturdays to talk with residents or to do an activity. The Inspector saw residents receiving visitors and meeting them in the lounge. The visiting relatives were complimentary about the care provided and felt their relative was being well cared for and the staff were friendly. Daily records were detailed and showed the choices made by residents, examples of which being their choice as to whether they participate in activities, whether or not to have a bath or shower or to go out for a walk with a care staff. Residents were seen throughout the day making choices from the meal eaten at lunchtime to returning to their bedrooms. Care staff showed a good awareness of the resident’s preferences and daily routines, including how to encourage a resident to make choices. The Inspector spoke with the cook, who had prepared gammon and vegetables for lunch with a choice of deserts. The cook said he is responsible for the ordering of food, using local stores, and purchasing fresh fruits and seasonal vegetables. The cook said he speaks with the residents to establish preferences, special dietary such as soft or liquidised meals or cultural appropriate meals. All the residents spoken with were complimentary about the meals provided, and all prepared by the cook. The Inspector saw care staff asking residents to chose the tea from the choice of menu. Residents said that they had a good choice on meals, including a roast on Sunday’s with all the trimmings. Two residents said they ‘very much enjoyed the meals’ to the extent that they need to reduce the portions and watch their weight. Residents described the selection of meals offered ranging from homemade soups and bread to full roast dinner and occasionally meals from different countries. The comments received from residents and visiting relatives included; “We visit nearly everyday and dad’s had a meal with mum here which was very good” “Food’s very good here, . . . . knows I found the meatballs a bit spicy yesterday” Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by a robust and accessible complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: Kingswood Lodge brochure contains the homes’ complaints procedure and set out in an easy to read style. The complaints procedure is displayed in the main reception area and the notice board along with details of social activities. Residents when asked were confident that should they have any concerns, whom they should speak with, in addition there is a written complaints procedure, and information as to how to contact advocacy services. Residents said they were aware their rights and said if they were not confident to tell the staff they would speak with their relatives in the first instance. Visiting relatives said they felt confident to express or raise concerns with any member of staff and confidant that it would be addressed promptly. The Registered Manager of Kingswood Lodge confirmed she has not received any complaints since the last Inspection. The information received in the PreInspection Questionnaire on the day, indicated that the service had received from concerns or complaints. Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 15 The Commission for Social Care Inspection has not received any expressions of concern about Kingswood Lodge. Care staff spoken with had a good understanding of their responsibility and procedures to follow in relation to safeguarding adults and was confident to whistle blow on poor or bad care practices. Staff training records examined confirmed that staff have received training in safe guarding adults as and as part of attaining a National Vocational Qualification (NVQ) in Care. . Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ benefit living in a clean, well maintained, safe accommodation, which is suitable for their needs. EVIDENCE: Kingswood Lodge is well maintained, decorated and furnished to a good standard, providing a comfortable and homely environment for the residents. The environmental improvements have taken place since the last Inspection, which includes new carpets in the lounges, corridors, stairways; new bath hoist, washing machine and tumble dryer. Kingswood Lodge is located close to Wigston town centre. Car parking is available to the front of the home. The small garden at the rear is mature and well maintained and looks out to the local church. Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 17 Kingswood Lodge benefits from three lounges and dining area to the ground floor, of which, one being designated as a ‘smoking lounge’ for those residents wishing to smoke. The Inspector saw a damp patch on the ceiling of one lounge. The Registered Manager said this was a result of a leak upstairs, which has been repaired and the area on the ceiling will be repainted once dry. The bedrooms are located on the ground and first floor, which are accessible using the stairs or the passenger lift located at the centre of the home. Shower, bathrooms and toilets are close to the resident’s bedrooms. Residents were seen speaking with the visitors in the lounges or in the privacy of their bedroom. The Inspector was invited to view two resident’s bedrooms, one on each floor. Both had en-suite toilet facility. The bedrooms were clean and reflected residents preferences, included personal furnishings. Bathrooms and toilets were clean and equipped with specialist equipment for the moving and handling of residents. The Inspector viewed the bathroom on the first floor and found personal toiletries, a dress hanging, hairbrushes and combs possibly belonging to residents. The Inspector noted the signed displayed for staff ‘not to leave residents’ personal toiletries and to return these items to their bedrooms’. This was brought to the attention of the Registered Manager, who accepted that staff had clearly not followed the instructions. The Inspector later returned to the same bathroom and found that the items had been removed. The Inspector spoke with residents who confirmed that in the main, their personal toiletries are taken into the bathroom and later returned to their bedrooms. Kingswood Lodge was found to be clean and tidy on the day and the domestic staff was seen cleaning the doors, windows and shampooing the carpet. The laundry room is situated away from the kitchen. The key workers were seen to be collecting the laundry and staff spoken with described the laundry procedure followed for soiled clothes for residents with any type of communicable disease. Care staff were seen wearing gloves and aprons when assisting with meals or assisting service users into the bathrooms. Residents also confirmed that staff did wear gloves when assisting them with personal care tasks. Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst staffing levels and deployment of staff are sufficient, the recruitment procedures and practices present shortfalls and does not adequately protect the residents. EVIDENCE: Kingswood Lodge employs sufficient staff to meet the needs of residents. Since the last inspection, Kingswood Lodge has appointed two new care staff. The staff rota seen was consistent with the staff on duty including the cook, kitchen assistant and domestic staff. The Inspector spoke with two care staff, of which one was on induction training. The experienced care staff had been employed for nine years and said she had all the pre-employment checks carried out including the renewal of the Criminal Records Bureau (CRB) check. The new care staff said she was appointed in January 2007 and was on induction training, working alongside an experienced staff. The Inspector checked the staff files for two staff, of which one was the new staff member on induction. Both staff files contained two written references. The Registered Manager confirmed that CRB clearance was satisfactory for the Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 19 experienced staff although could not demonstrate or show any reference of the CRB disclosure number, as the records were not kept at the home. The Registered Manager gave assurance to make available on request evidence to show that CRB checks are in place. The pre-inspection questionnaire received from the Registered Manager on the day indicated existing staff did have CRB checks in place. However, no evidence of protection of vulnerable adults (POVA) first check had been carried out for the new care staff and no evidence that a CRB disclosure had been applied for. This indicated that Kingswood Lodge’s recruitment procedure and practices raised concerns and placed residents at risk. The Inspector issues an Immediate Requirement to the Registered Manager, to carry out a POVA first check in the first instance, within 24 hours. Kingswood Lodge has 57 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, which was consistent with the information detailed in the pre-inspection questionnaire. Training completed by staff included: manual handling; safe guarding adults, dementia awareness, fire safety, infection control; basic care skills and food hygiene. Staff spoken with including the new care staff were aware of their roles and responsibilities, where to find the home’s procedures and who to report any concerns to. Staff said they generally felt supported by the senior carers and the Registered Manager. Staff spoken with stated that they have small staff meetings although no records were available to confirm staff meetings do take place. Residents that spoke with Inspector felt that they were understood. Staff were seen responding to residents promptly and assisting residents from the wheelchair to the armchair, using safe techniques, encouraging the resident to do as much as possible, safely. Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager offers a sense of leadership, ensuring residents health; safety and welfare are promoted, although evidence to demonstrate self-monitoring and staff supervision could be improved. EVIDENCE: The Registered Manager has many years experience of working and managing Kingswood Lodge. The Registered Manager has clear lines of responsibility and accountability for all the staff at the home, and is supported by the Senior Carers. Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 21 Residents care records showed care needs were being reviewed with the residents at least monthly or more frequently, if care needs changed. Residents confirmed that they were asked about the care received to make sure it was right for them. The visiting relatives said they were informed about any changes to the resident, as they advocate for them. The Registered Manager said the Registered Person when required provides additional management support. The Registered Manager confirmed that the Registered Person does the monthly visits. However, no records were available detailing the findings from the visit that would demonstrate their duty and obligation to the regulation is met. The Registered Manager confirmed that the quality assurance questionnaires are being sent out to the residents and their relatives to seek their views about the home, the care, staffing and any suggestions or areas of improvement. A copy of the resident’s and the relative’s questionnaire produced was seen by the Inspection to confirm the information received. The Registered Manager said that any shortfalls or concerns that come out of the survey would be addressed. The Registered Manager said the findings and actions taken would be made available, to the Commission if requested. A file is kept of all the comments, cards and letters received from residents and their relatives. These included: “To all at Kingswood Lodge for looking after me so well for 2 weeks. Hoping to see you next time” “Thank you for making my stay here so wonderful. You have all made me feel so much at home” “I would like to take this opportunity to thank you and all of the staff at Kingswood Lodge for providing her with the much needed care and attention she deserved these past six years . . . . . you became her second family”. Residents spoken told the Inspector they are given the option to have keys to their bedrooms and have lockable cabinets in their rooms. The residents confirmed they manage their own financial affairs with the support of their family and other resident spoken with indicated if they wanted their money to pay for hairdresser or go shopping they usually get the money immediately and sign for it. Where small amount of money is held on behalf of the resident, a record of the balance with receipts is kept and requires the signature of the resident (if possible) and at least signatures of two staff. Records viewed showed good arrangements were in place to manage resident’s finances and demonstrated there is a clear procedure for handling money. The resident’s records were up to date with detailed information to guide staff and provide key information to health care professionals. Assessments of risk Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 22 for falls and moving and handling were carried out and in the care files for all the residents. Residents spoken with were confident to access their records. Staff said the ‘staff team meetings’ do take place along with staff supervision. However, there was no information or records available to show staff received supervision. The Pre Inspection Questionnaire received on the day detailed the regular maintenance of health and safety systems within the home, including fire systems and equipment, central heating systems and emergency call systems. Kingswood Lodge has a planned programme of maintenance. The accident/incidents records viewed were the same as those sent to the Commission. The cook confirmed he maintains details records relating to fridge temperatures, checks at opening and closing of kitchens. The cook said the Environmental Health Officer had inspected in September 2006 and no issues arose from the visit. Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 23 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 HOICE 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 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 2 3 3 Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 19 Requirement The Registered Person shall not employ a person to work at the care home unless; Protection of vulnerable adults (POVA) first check is carried out within 24 hours, for the named member of staff. The Registered Person shall visit the care home at least once a month; Seek the views of the residents 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. Timescale for action 08/03/07 2 OP33 26 07/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 25 1 OP29 2 OP36 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. The Registered Persons should ensure all staff receives formal supervision at least six times a year, covering all aspects of practices in the care home, which is recorded and a copy for the staff. Kingswood Lodge DS0000001738.V329965.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Leicester Area Office 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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. 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