Inspection on 21/10/05 for Kingswood Park

This inspection was carried out on 21st October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Park 19/11/08

Kingswood Park 24/11/06

Kingswood Park 08/06/05

Kingswood Park 18/01/05

Kingswood Park 28/04/04

Kingswood Park 11/03/04

Similar services:

Claremont House

Oak Ridge

Coopers Mill Ltd

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Paradise Lodge

Bilney Hall

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

CARE HOMES FOR OLDER PEOPLE Kingswood Park Kingswood Road March Cambridgeshire PE15 9RT Lead Inspector Don Traylen Unannounced Inspection 21st October 2005 10:00 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 Park DS0000015196.V260270.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 Park DS0000015196.V260270.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kingswood Park Address Kingswood Road March Cambridgeshire PE15 9RT 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) 01354 652381 01354 660304 s.berkeley.amr@mha.org.uk Methodist Homes for the Aged Mrs Sumiyo Berkeley Care Home 44 Category(ies) of Dementia - over 65 years of age (18), Learning registration, with number disability over 65 years of age (2), Old age, not of places falling within any other category (44) Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing levels must not fall below 7 care staff from 7.30am - 10pm and 3 waking night staff throughout the night. 23rd May 2005 Date of last inspection Brief Description of the Service: Kingswood Park is situated in a quiet residential area of March. It is owned by Methodist Care Homes, who purchased the property from Cambridgeshire County Council in November 2001. The home is registered to provide for 44 elderly people. Included in that number are a maximum of 18 people with a formal diagnosis of dementia and 2 people who have a learning disability. The home is divided into 5 units: Cherry, Redwood, Rowan, Maple and Willow. Each unit has 8 or 10 bedrooms, a dining room, a lounge and a kitchen. One unit is designated for people with dementia and another unit is for service e users with high dependency needs. These two units are accessed via a door with a combination lock. All bedrooms are on the ground floor of the building. The manager’s office, the administration office, a staff meeting/training room, staff toilets and relaxation room and staff kitchen are situated on the first floor. A large central room is used for a community Day Centre provision. This operates three days each week on Monday, Wednesday and Friday and offers 22 places. The Day Centre is staffed as an independent provision, separate from the home’s staffing arrangements. On Tuesdays and Fridays the room is used by service users who participate in various social activities, organised by the home’s activities co-ordinator. Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector conducted the inspection on the 21 October 2005. The inspector carried out a tour of the home and observed and spoke to the assistant manager whilst he was administering medication. Two service users were spoken to and two service users’ care plans and two service users’ assessments were read. One cook provided information about the arrangements for the running of the kitchen. What the service does well: What has improved since the last inspection? What they could do better: The home must consider employing more care staff. During the inspection the home was operating on the minimum numbers of staff that are cited as a Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 Page 6 condition of their registration. During this inspection and during the last inspection it has been reported that at times the inspector could not easily summon any care staff. There were six care staff and one assistant manager on duty during the morning of the inspection. The assistant manger was occupied for most of the inspection administering medication. The assistant manager is responsible for medication for the entire home when on duty and this task alone was observed to occupy the assistant manager for a considerable amount of time. The admission and care [planning process can be improved. Assessments undertaken by the home contained minimal detail and must be more searching in their contents and description of the person. Care Plans must be comprehensively improved so that more information about the person and their known and unfolding care needs are recorded and a description of how to meet these needs is recorded. Dementia care training must be revisited and undertaken by all care staff employed by the home so that the staff have a recent or current understanding of dementia care practice. Medication records must be improved. 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 Park DS0000015196.V260270.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 Park DS0000015196.V260270.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): 1,3,4,5, A similar judgement prevails as at the last inspection of the 8 June 2005: the detailed assessment information can be improved upon. EVIDENCE: Two assessments for two service users that were undertaken by the home contained minimal detail. Service users had not signed their assessment. One assessment did not contain any details regarding reason for admission under the heading in the assessment form; there was no admission date, very few details had been recorded and there was a recording of “multi-infarct dementia”. Assessments conducted by the home should be more searching in their contents and in the description of the person. Staff training should be considered to improve their ability to assessment and to record this information. The last inspection report contained the Requirement: “The home must analyse the assessment details they are provided with from PCT employed Care Managers so they fully understand their undertaking and ensure that full and comprehensive assessment details are in their possession before agreeing to provide respite care. “ Although this Requiremenmt was directed at respite care arrangemenst, the Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 Page 9 same praxctice must apply to all asseessment information gathered by the home. Therefore, if minimal assessment details are recorded by the home, it remains to be questioned wether or not the home can meet service users needs. Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10, Care Plans do not adequately describe or address needs. EVIDENCE: Two Care Plans were read. There were unqualified comments about ”disturbance to others”, written in one Care Plan. Another Care Plan kept diaries of personal needs although there were many recordings of “no change” written that did not explain what were the needs. Another care Plan did not have a date of admission and despite having been assessed by the Mental Health Services on 23/6/05, there were only minor details on the assessment and Care Plan complied by the home. There were details of the service user’s contract with the home as a self-funding service user, but the Care Plan had not been completed on the date of inspection. Care Plans must be comprehensively improved so that more information about the person and their known and unfolding care needs are recorded and a description of how to meet these needs is recorded. The last report made in 8 June 2005 stated, “The Statement of Purpose that states care is ‘person centred’, must be mirrored in the Care Plan and in the personal interaction when giving care. This has not been shown when tracking this service users’ care planning. The Service User Guide that states Care Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 Page 11 Plans, ‘detail all your nursing………requirements’ and ‘your key worker will use the care plan to inform other staff of your particular needs and wishes’ “. Care Plans read during this inspection did not uphold this claim. Medication Administration Record (MAR) sheets were checked for the amount of medication recorded by the home at the start of the four-week period. One entry had been incorrectly recorded. The inspector and the assistant manager checked and re-counted the medication and agreed that the incorrect amount had been entered at the start of the MAR sheet. The assistant manager was able to establish the correct amount and as no medication had been administered he immediately corrected the recording. It is required that the amounts of the prescribed medication are checked and are recorded correctly at the start of each entry on the MAR sheet. Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Not Applicable on this occasion. Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Service users’ or relatives’ complaints are listened to and acted upon. EVIDENCE: All staff have satisfactory CRB checks. Methodist Homes conduct a searching recruitment process where references and work histories are checked. The training records show that nearly all staff have undertaken Adult Abuse training organised by Cambridgeshire Community Services. The home has responded positively and openly to previous complaints and to allegations of abuse. The manager maintains a record of all complaints. At the last inspection staff stated they were aware of abuse but were not confident about how to report abuse or where the telephone contacts were kept when asked. The Duty office used by all care staff and assistant manager had a clear list of names and telephone contacts for the Police or Social Services/PCT and CSCI. Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26, The homes is well maintained and has a comfortable and suitable environment for service users. EVIDENCE: The environment of the home has previously been established as high quality and well maintained. Observations were made of the very clean kitchen, bathrooms and toilets, communal areas and bedrooms. There were no offending odours noticed during the inspection. Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 Page 15 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): 27,28,29,30, Staff skills and the minimum staff numbers do not meet all the needs of service users. EVIDENCE: During the inspection the home was operating on the minimum numbers of staff that are cited as a condition of their registration. When the inspector arrived unannounced at the home, the door was open and there were no staff available to speak to until the inspector sought out staff some distance away from the main entrance. The inspector then had to ask who was the person in charge. The duty manager’s office was empty and the door left open. Service users living in the community were arriving to attend the day centre. During this and the last inspection of the 8 June and 14 July 2005, it was noted that at times the inspector could not easily summon any care staff: “At one point during the inspection the inspector could not find a member of staff. Three service users who were observed to be sitting in the dining area after lunch were not noticed by passing carers, nor were they spoken to directly by care staff when care staff did re-appear. Observable evidence shows that staff are not attendant to service user at all times and that they are not all sufficiently engaging with service users..” The home employs 1 manager, 4 assistant managers, 44 care assistants (including 8 night staff), an administrator, 2 cooks, 8 domestic workers and a gardener and a laundry worker. 6 care assistants and an assistant manager were working at the time of inspection. The assistant manger was occupied for Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 Page 16 most of the inspection administering medication. The assistant manager is responsible for medication for the entire home when on duty and this task alone may occupy the assistant manager for a considerable amount of time. The home is a large home with four units interconnected by long and spacious corridors and it was observed that service users were alone and unattended in the various parts of the home. Three care staff usually work in the extra care units for Maple and Willows where there are up to 18 service users with a diagnosis of Dementia. Staff are expected to share the responsibilities for all the service users needs, rather than have dedicated staff employed within each part of the home. However, three care staff work regularly with the service users in Maples and Willow units. 14 care staff including, the assistant managers, have achieved NVQ level 2 awards. 7 further staff are awaiting confirmation or are undertaking NVQ level 2 awards. 6 staff have achieved or are undertaking or awaiting confirmation of NVQ level 3 awards. Two assessments conducted by the home contained only minimal information as did the Care Plans for these same service users. Staff training must be provided to improve their ability to conduct and record service users’ assessment information. Staff training in ‘Care Planning’ must be provided so that staff have an improved understanding of care planning and of the importance of maintaining a comprehensive record of care. Training records indicated that 17 of the 32 staff who have received training in dementia care did so more than 3 years previously. Staff who have received this training have been recorded as receiving this training on only two occasions: 2002 or 2004. Arrangements must be made for all staff to undertake current and topical training in Dementia care so that all staff have received this training within the last year. This training must be revisited at periodic intervals to facilitate staff to have continuous understanding and interest in Dementia related care needs and so that the home is able to meet the projected needs of older people with dementia in the wider community. The above evidence indicates various raining needs and as well as the need for extra staffing. In the last inspection report the inspector noted there were occasions when 7 care staff had worked during the morning shifts. However, on this occasion there were only six care assistants. The next inspection will include observations of the frequency, the quality and effect of interaction between service users and staff. Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,37, The home is well managed and is run openly and professionally. EVIDENCE: The manager continues to meet Standard 31. She is service user focussed in her approach to managing. As stated in the last report the service user survey/ questionnaire was available in the main hallway along with the Statement of Purpose and Annual Report. The home is subject to Methodist Homes’ internal service inspection. However, increased attention to care planning arrangements should be the focus of quality assurance. Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 Page 18 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 X 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 x 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 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X X 3 x Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1)(a)( b)(c)(d) Requirement Assessments undertaken by the home must be more searching in their contents and description of the person. Regulation: 14(1)(a)(b)(c)(d) Timescale for action 01/12/05 2 OP7OP4 15(1) &(2)(b) 3 OP9 13(2) Care Plans must be generated 01/12/05 from a comprehensive assessment and must be improved so that more information about the person and their known and unfolding care needs are recorded and a description of how to meet these needs has been recorded. Care Plans must. Part of the Requirement made in the last inspection of the 8 June 2005 remains unmet: “Care Plans must be accurately recorded and contain all care arrangements”. Regulation: 15(1) &(2)(b) The numerical amounts of the 01/11/05 prescribed medication must be thoroughly checked and recorded correctly at the start of each entry on the MAR sheet. Regulation: 13(2) DS0000015196.V260270.R01.S.doc Version 5.0 Page 20 Kingswood Park 4 OP30 17(1a)18( 1a&c)&Sc h3 5 OP30 17(1a)18( 1a&c)&Sc h3 18(1)(a) (c) 6 OP30 Training in assessing service users needs must be provided for key staff who conduct assessments of service users. Regulation: 17(1)(a) & Schedule 3, & 18(1)(a)(c) Training in care planning must be provided for key staff. Regulation: 17(1)(a) & Schedule 3, & 18(1)(a)(c) Training in Dementia related care must be provided for all care staff and this training must be provided for all staff. Dementia care training must be a continuous and permanent training topic. Regulation: 18(1)(a)(c) 01/12/05 01/12/05 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. NA Refer to Standard NA Good Practice Recommendations . None Kingswood Park DS0000015196.V260270.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Park DS0000015196.V260270.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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