CARE HOMES FOR OLDER PEOPLE
Kingswood Lodge Long Street Wigston Leicestershire LE18 2BP Lead Inspector
Helen Abel Unannounced Inspection 7th November 2005 12:15 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.V262698.R01.S.doc Version 5.0 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.V262698.R01.S.doc Version 5.0 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 2884632 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.V262698.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 1st July 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. Kingswood Lodge DS0000001738.V262698.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection during a weekday morning over a 3-hour period. A full tour of the building took place with care records, policies and procedures inspected. There was the opportunity to talk with five residents and staff were also interviewed. The Registered Provider spoke briefly with the Inspector on the phone and the Registered Manager was present at the inspection. What the service does well: What has improved since the last inspection? What they could do better:
Arrange training for staff that administers insulin to meet resident’s health care needs. Undertake repairs and improvements to communal carpets, a lounge and identified bedrooms. This will provide a safe, well-maintained environment for residents to enjoy. To address a shortfall within the staff team, and cover domestic duties in order to maintain a clean and hygienic environment.
Kingswood Lodge DS0000001738.V262698.R01.S.doc Version 5.0 Page 6 Obtain information to meet the requitments for staff recruitment records and further safe guard residents. Develop the assessment format to ensure all the necessary information is recorded. Arrange regular trips out for residents who wish to participate, in order for individuals to enjoy an active lifestyle. 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 DS0000001738.V262698.R01.S.doc Version 5.0 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.V262698.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 Assessment processes are fully implanted, which ensures that the service meets prospective residents needs. EVIDENCE: All residents are assessed prior to entering the home. The Registered Manager will undertake the assessment often with families and friends or other professionals involved in the residents care. Suggestions were given around how to improve assessment format to ensure everyone contributing to the assessment is reflected on the written format. Kingswood Lodge DS0000001738.V262698.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Residents health, personal and social care needs are generally met. EVIDENCE: Care plans were examined and found to hold the appropriate and relevant information. The resident’s medicine records were examined and were compliant. The administration of medicines systems were in good order. Policies and procedures were in place around death and dying with training available to staff. Staff are trained to be respectful when dressing, bathing and seeing to residents medication procedures. The home should arrange training for staff around administering insulin for an identified resident. Residents with significant health care needs were found to be given good support and care by staff. Kingswood Lodge DS0000001738.V262698.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All these outcomes were inspected at the last inspection visit and were found to be compliant. EVIDENCE: Kingswood Lodge DS0000001738.V262698.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17,18 Resident’s legal rights are protected. EVIDENCE: The Registered Manager confirmed residents were all given polling cards for the recent election. Some residents sent off votes others went out to vote at their local polling stations. The complaints procedure was displayed on the resident’s notice board and is due to be reformatted for easy reading. Kingswood Lodge DS0000001738.V262698.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25 The premises were generally well maintained clean and comfortable. EVIDENCE: Bedrooms were inspected and were bright and comfortable. Each room is personalised with resident’s possessions and items of their own furniture. All the communal area carpets were badly marked and worn. The Registered Provider confirmed they would be replaced by December. Three identified rooms presented with an odour and one door was found to be creaking and needs repair. A filing cabinet was found in the communal smoking lounge for staff use and should be removed. It was noted smoke from residents smoking in the designated lounge was coming through into the adjoining corridors, rooms and into the lift. There was no mechanical or natural ventilation available in the smoking lounge. Staff confirmed windows are never opened. Options should be explored around improved ventilation in this area. Kingswood Lodge DS0000001738.V262698.R01.S.doc Version 5.0 Page 13 The outdoor areas are well maintained with a private green lawn and garden furniture at the back of the home. Kingswood Lodge DS0000001738.V262698.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 Overall staffing levels were sufficient but the deployment of domestic staff must be addressed. Recruitment policies and procedures present shortfalls and do not adequately protect residents. EVIDENCE: The domestic staff member was away for a long period and no cover has been provided. This has impacted on care staff who have had to undertake some of these duties. The deployment of a temporary domestic cover should be arranged to maintain hygiene standards in the home. Residents were observed enjoying a game of dominoes with a helper in the home. Wooden puzzles and quizzes are also regularly organised. Staff recruitment files were examined and did not include all the required information. The files need better organisation. Completed staff induction packs were evident and criminal record checks were kept up to date. Kingswood Lodge DS0000001738.V262698.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,38 Residents are consulted about life in the home. The home promotes the health, safety and welfare of people using the service. EVIDENCE: Five residents were interviewed and gave the following comments: “The beds are good.” “We don’t go on any trips, it’s boring. I get up and go to bed when I want.” “We are going to Rutland Water” “I hade egg and bacon flan with scalloped potatoes today followed by apple pie and custard. The food is very good. The carers are good to me. I have nothing to complain about.” “The staff are good to me. They buy my toieltteres” The issue around trips out was discussed with the Registered Manager. She confirmed a recently organised trip had been cancelled, but small trips out for individuals were being arranged.
Kingswood Lodge DS0000001738.V262698.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 x 2 x x x x x 2 x STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x x x x 3 Kingswood Lodge DS0000001738.V262698.R01.S.doc Version 5.0 Page 17 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 OP8 Regulation 12 Requirement The Registered Person shall ensure that the care home is conducted so as to: (a) To promote and make proper provision for the health and welfare of residents. Staff whom administer insulin to receive training from the District Nurse. The Registered Person shall ensure all parts of the home to which the residents have access are safe and well maintained: Take action with the three identified rooms that present with an odour and to remove the staff filing cabinet from the smoking lounge. 07/11/05 Timescale for action 07/11/05 2 OP19 13 3 OP25 23 All communial area carpets to be replaced Ventilation is suitable for 30/11/05 residents and is provided in all parts of the home which is used by the residents: Options must be explored around improved ventilation in the smoking lounge.
DS0000001738.V262698.R01.S.doc Version 5.0 Page 18 Kingswood Lodge 4 OP29 7 5 OP27 18 Information and documents to be held including in respect of person working at the home: 1. Proof of the person’s identity, including a recent photograph. 2. The person’s birth certificate. 3. The person’s current passport. 4. Documentary evidence of any relevant qualifications of the person. 5. Two written references relating to the person. The Registered person shall ensure that at all times suitably qualified competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of residents: Ensure domestic staff are provided to ensure standards relating to hygiene are kept. 30/11/05 07/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations Review and update the assessment format and include the following: The date the assessment took place; the names and signatures of individuals that contributed; the name and signature of the new resident (where applicable); and name and signature of the staff undertaking the assessment. Review the opportunity for trips out for all residents who wish to join in (where applicable). 2. OP27 Kingswood Lodge DS0000001738.V262698.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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