Inspection on 18/09/08 for Kiniths House

This inspection was carried out on 18th September 2008.

CSCI found this care home to be providing an Good service.

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

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Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

CARE HOME ADULTS 18-65 Kiniths House 33 Kiniths Way Halesowen West Midlands B62 9HJ Lead Inspector Linda Elsaleh Unannounced Inspection 18 & 19 September 2008 3:30 th th Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 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 Kiniths House DS0000071454.V372323.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 Adults 18-65. 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. Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kiniths House Address 33 Kiniths Way Halesowen West Midlands B62 9HJ 0121 602 1279 0121 602 4216 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) Kiniths House Ltd Ms Lindsay Denise Price Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning Disabilities (LD) 9 The maximum number of service users to be accommodated is 9. 2. Date of last inspection 18th September 2007 Brief Description of the Service: Kiniths House is a large traditional detached property. It is located in a residential area of Halesowen, with easy access to local amenities such as shops, pubs, post office and public transport. The same family has owned the home since it opened in 1986. It provides a home for up to 9 younger adults who have varying degrees of learning disabilities. There is off-road car parking at the front of the property. There is a small patio/garden area at the rear of the premises. The communal areas comprise of small reception lounge, main lounge, conservatory/dining area, kitchen, laundry, bathing and toilet facilities, one shared and seven single en-suite bedrooms. Information about the home and the service it provides are available in the Statement of Purpose and Service User Guide. The home should be contacted for information about the fees charged. Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. This unannounced inspection was carried out on 18th & 19th September 2008. The purpose was to assess the home’s performance against the key standards in the National Minimum Standards for Care Homes for Adults and report on the progress made to address previous requirements. Our findings are based on the information received by the Commission for Social Care Inspection (CSCI), examination of relevant records and documents kept at the home and discussions with the manager, staff on duty and people who live in the home. The atmosphere within the home was relaxed and friendly. A tour of the premises found it to be suitably furnished, clean and tidy. People we spoke to expressed satisfaction with all aspects of the care and support being afforded to them. What the service does well: What has improved since the last inspection? Minor work has been carried out on the environment such as replacing the stained carpet in the shared bedroom as well as the re-decoration of some rooms. There have been improvements in the way the home records health and safety issues, for example the monitoring of fridge and freezer temperatures. The Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 6 names of staff and people present during fire drills are recorded and monitored to ensure everyone is aware of what to do and staff know whether any person requires assistance in the event of an emergency. Work continues to be carried out to improve the home’s approach to personcentred planning. Individual risk assessments have been developed further to ensure all areas of potential risk are identified and strategies put in place to minimise these. Regular individual supervision sessions are being provided for staff. A more detailed training programme has been produced to enable staff to update their knowledge and develop their skills to ensure people’s continue to be met appropriately. 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. Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is adequate. The Statement of Purpose and Service User Guide needs to be reviewed to ensure people are provided with information about the service that is up to date. These should be provided in suitable formats that enable them to understand the contents to enable them to make an informed choice about where they wish to live. There are procedures for assessing the needs of individuals who may wish to live in the home to ensure the service is able to meet their needs and aspirations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a Statement of Purpose and Service User Guide. These documents need to be reviewed following the approval of the home’s application to increase the registered number of people who live here from seven to nine. The manager told us she plans to review both documents and produce them in suitable formats that will be easier for people to read and make an informed choice about where they wish to live. Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 9 At the time of this visit there were seven people living in the home. There have been no new admissions for over four years. Four of the seven people living at the home have been resident for 22 years. Information provided by the home states its referral and admission procedure was reviewed in April 2008. The manager told us as well as the care assessment provided to them the home carries out its own assessment before a placement is offered. This includes giving consideration to the compatibility of the individual with the existing group of people who live in the home. Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is adequate. People living in the home should be fully supported to participate in the development of their care plans and these should be regularly reviewed in order for the individual and/or their representative to be confident their assessed and changing needs and personal goals are reflected in their individual plans. The home supports people to make informed decisions about how they wish to live their lives and consults with them about all aspects of life in the home. A suitable process is in place to support people, wherever possible, to take risks as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 11 Since our last visit the manager has revised the care plan for one person who lives at the home. She told us this person is unable to actively participate in identifying and planning to meet her/his care needs. We looked at the care plan and found it contains clear objectives, with long and short-term goals, and details of how the person’s needs are to be met. It includes a system for recording progress that is used to inform the monitoring and review process. The manager told us arrangements were being made for staff to receive training in person-centred planning and the mental capacity act. Once the training has been completed staff will support individuals to actively participate in the process for identifying their care needs and planning how these will be met. Care plans will be produced in formats that are best suited to the understanding of the individual. We looked at the individual risk assessments held in people’s files and found these cover issues of any potential for harm to be caused, such as mobility, bathing and mealtimes. These are reviewed regularly and amended to reflect any changes to how risks are to be managed. The care plans for three people living in the home have been reviewed during the last six months. Attendance at these meeting included people who are significant the individual’s life, such as relatives and other professionals. A review for another person is planned to take place in a couple of weeks and reviews for the other three people who live in the home have yet to be arranged. We discussed with the manager the need to develop a system to ensure reviews take place regularly, at least once every six months, to ensure the needs of individuals continue to be appropriately met. Staff told us how the needs of people are met. For example, they described how they assist one person with her/his personal care in accordance with their care plan and personal preference. Staff also told us they had recently attended client-centred training to improve their knowledge and develop their skills in meeting the needs of people with dementia. One member of staff told us the course was a good introduction and felt s/he would benefit from attending a more advanced course on the subject. A record of when individual staff members attended this training was seen on their files. We spoke to people who live in the home. They told us they are able to live the life they choose and are pleased with the care and support provided by staff. They are asked how they wish to spend their time and what support they need to help them complete specific tasks. For example one person told us they were receiving held to complete an application form for a job s/he is applying for. Information is displayed in a user-friendly format on the residents’ notice board in reception. Two people living in the home provided us with more detail about the information on display demonstrating that they are regularly Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 12 consulted about issues on how the home is run. Formal house meetings are held four or five times a year for which minutes are kept. Staff told us people enjoy these meetings, especially planning group activities such as the Christmas play to be performed for relatives and other visitors to the home. Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. People are able to participate in appropriate activities in the home and in the community. They are supported to maintain contact with family and friends. Staff respect people’s right to follow their own routines and provides them with support where required. The home provides varied and healthy meals, which meet people’s individual needs and personal preferences, and are served in pleasant surroundings. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since our last visit the manager has made arrangements for people to spend more time with their key worker on an individual basis. One person told us s/he is being helped to improve their reading and writing skills and is in the Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 14 process of completing an application for a job. Some people attend a local day centre and/or college placement. We observed people being welcomed home by staff and were eager to discuss the events of their day. Staff informed us the local authority is significantly reducing its day care service. Two people living in the home told us they were unhappy about this. One person told us they had been able, with the support of staff, to renegotiate the day they attend the centre so they could continue to participate in their favourite activity. The manager told us the home is looking at how it can best plan to meet people’s needs due to this change. People who spoke to us said they had a good social life and enjoyed the trips arranged for them by the home. These included visiting places of interest and eating out. One person told us they had enjoyed two holidays this year. A variety of board games are available and some people have entertainment equipment in their bedrooms such as a television, music centre and/or a computer. On the first day of our visit people were eager to discuss the party they were going to the following evening, the present they had bought, the clothes they were going to wear and who they expected to be there. During the evening most people chose to sit and watch a video together in the lounge. People are encouraged to maintain contact with others who are important to them and are supported by staff to make telephone calls or write letters. Family and friends are welcome to visit the home at any time. The home also arranges transport for people to visit them. Each person has a folder where records are kept of important information regarding a range of daily events. These showed us that routines in the home are flexible and meet the individual needs of the people who live here. For example people are provided with a key to their own bedroom and are able to spend time in their room whenever they choose. On our arrival one person who lives in the home made us a hot drink. We chatted to people about meals and mealtimes and they told us they like the meals that are provided for them. A record is kept of people’s likes and dislikes. Staff discussed with one person what they would like for their evening meal, as she was aware the choice of menu was not to the person’s liking. The daily menu is produced in a pictorial format and a booklet is available to assist people, if they wish to choose alternative meals. The records of meals taken show, with the exception of breakfast, people usually choose the same lunchtime and evening meal options. The home does not employ catering staff. Members of the care staff team prepare all meals and snacks in the appropriately equipped kitchen. Information provided by the home show the majority of staff had received training in basic food hygiene. People living in the home sometimes spend Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 15 time in the kitchen helping to prepare drinks and snacks. Individual risk assessments have been carried out to ensure people are safe. Mealtimes are regarded as a social occasion and people tend to eat together at the dining table in the conservatory. One person helped to lay the table and another put on some background music. People chatted about different topics throughout the meal. The meals were served by staff to meet people’s individual needs and preferences and they provided support throughout the meal, where required. Information about the support one person requires with meals and mealtimes was seen on her/his care plan. Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. People living in the home are provided with personal support to meet their individual needs and preferences. The home consults regularly with health care professionals to ensure a person’s physical and emotional health care needs are met. Suitable procedures and systems are in place for ensuring current medication is being managed safely on the behalf of the people who live in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans show people’s preferred routines for example the time they normally like to get up or retire to their bed. Detailed information is also kept of how people like to be supported with their personal care. One person explained to us how they like to be supported when taking a shower and confirmed staff do provide them with this support. This information is detailed in her/his care plan. Staff we spoke said they follow the care plans and Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 17 ensure a person’s dignity is respected when they are being assist with personal care. For example, personal care is always provided in the privacy of the person’s own room or bathroom and visits made by health care professionals always take place in the person’s own room. There are good systems in place to ensure people’s health care needs are met. Records are kept of visits made to or by health care professionals. This shows us people receive regular routine healthcare checks from professionals such as their doctor, dentist, optician and chiropodist. The home also ensures steps are taken to monitor people’s well-being and, where appropriate, preventative measures are taken. For example, weight checks are undertaken, where applicable, and a nutritional screening tool is used to identify what action should be taken in the case of significant loss or gain in weight. One person, who received treatment from the district nurse for a pressure sore which has since healed, continues to be identified as being at risk and is provided with a pressure-relieving mattress. The home seeks medical advice for any aspects of a person’s health they are concerned about. Five of the seven people living at the home have medication prescribed for them on a regular basis. The home looks after the medication for these people. There are suitable arrangements for the safe storage of medication. Information provided by the home shows it last reviewed its procedures for the safe handling and administration of medication in April. The records we looked at show staff responsible for managing medication had been trained to carry out these duties. Individual medication administration record (MAR) sheets are kept and appropriately completed. At the last inspection it was recommended that a system be introduced for recording medication that is taken out of the home, for example when an individual is away overnight. The manager told us this had not yet been addressed. She was also advised to ensure suitable systems are in place for managing controlled medication should a person be prescribed this at any time. Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. A copy of the home’s complaints procedure is made available to people who live at the home. Additional systems are also in place to ensure people’s views are listened to and acted upon. Safeguarding procedures are available and training is provided to staff in order for people to be protected from abuse, neglect and self-harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about the home’s complaints procedure is available in the Statement of Purpose and Service User Guide. It is also displayed in the home and provided in alternative formats. Our records show no complaints have been reported to us about this service. Information provided by the home also states no complaints have been received by them. People we spoke to told us they knew how to make a complaint and whom they would speak to if they had any concerns or where unhappy about anything. They said they were confident the home would appropriately deal with any issues they might raise. One person told us “all the staff are very nice”. Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 19 Adult protection policies and procedures are also available in the home and accessible to staff at all times. Staff records we looked at show training is provided for safeguarding vulnerable adults. Staff we spoke with confirmed they had received this training and were familiar with the procedures to be followed should any concerns be raised. There have been no reported adult protection issues and no concerns were identified during this visit. Staff we spoke to said the home has a ‘no restraint’ policy. They told us about one person who sometimes displays challenging behaviour and described how they respond to such incidents in accordance with her/his care plan and risk assessment. They said they had not witnessed any behaviour or been involved in any incident with a person living in the home that required the individual to be held for their own safety or to ensure the safety of others. Records are kept for personal allowances managed by the home on people’s behalf. Two members of staff sign these and receipts are obtained for all purchases. Staff support people to access their money but do not hold any information about personal identification numbers. The manager regularly audits these records. She does not act as appointee for any person living at the home and the role continues to be carried out by the previous owner. Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. Arrangements are made to ensure people live in a homely, comfortable and safe environment. There are procedures available for staff to follow to ensure the home is kept clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A person who lives at the home invited us to have a tour of the premises. We were shown all the communal areas and some people showed us their bedrooms. There is an attractively landscaped courtyard with a fishpond that is provided with a suitable guard to minimise the risk of any accidents occurring. Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 21 The communal areas consist of a small reception lounge, main lounge and conservatory where meals are served. All areas are suitably furnished and decorated to a good standard. As previously mentioned, there is a large notice board in the hallway that displays a range of useful information with pictorial prompts and booklets about various topics such as activities and skills for life. Bedroom doors are fitted with suitable locks and keys are provided to people whose rooms these are. All rooms are furnished to reflect the individual’s preferences. Three people told us of plans for their bedrooms to be redecorated in the near future. The registered manager and responsible individual confirmed these arrangements were being made. The personal possessions on display provide each bedroom with its own atmosphere. One person has her/his own computer and some people have their own television and/or music centre. The carpet in the shared bedroom has been replaced. The people who occupy this room told us they are good friends and do not feel the need to use the wicker screen provided for their use should they wish more privacy. The responsible individual told us arrangements are being made for additional sockets to be fitted in two people’s bedrooms. The laundry area is situated at rear of the premises. Procedures and guidance for the control of substances hazardous to health (COSHH) and infection control is available to staff together with personal protective clothing for when they are carrying out domestic, catering or personal care duties. The records we sampled showed staff had received appropriate training in this area. The home was clean, tidy and free of malodours throughout this visit. Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 22 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. A stable and competent staff team provide support to the people who live in the home. People are benefiting from the planned approach being taken to provide training to staff and arrangements made for them to receive individual supervision on a more regular basis. Recruitment processes for new staff safeguards the people who live at the home. These safeguards will be further improved once the home has made arrangements to ensure full details are obtained about the work history from applicants. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The team is made up of female and male care staff from different age groups and life experiences. The majority of the team members have several years experience of working with people with learning disabilities. The home Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 23 provides all staff with training in the National Vocational Qualification (NVQ) Level 2 and includes the elements for working with people with learning disabilities. Members of the senior staff team have achieved, or are in the process of undertaking, the NVQ Level 3. The manager told us that until recently the home had a full complement of staff and absences are covered by the team to ensure people receive a consistent level of care. We were informed arrangements are being made to recruit to the vacant full time and part time positions. It has been over twelve months since a new member of staff has been employed by the home. The recruitment records checked during out last visit showed that no staff had been employed without all pre-employment checks being carried out. However, the manager was reminded of the recommendations made during that visit to revise the application forms and request for references to ensure a full employment history is obtained, including the dates a person commenced and ceased employment. A written explanation should be provided for any gaps in the applicant’s work history, these should be explored with the applicant and a written record kept of the discussions held on their recruitment file. This is to ensure the best interests of people living in the home are fully protected through a fully robust recruitment process. The manager has produced a more comprehensive in-house induction process for newly appointed staff and put in place systems for ensuring staff complete the Common Induction & Foundation Standards, that meets the Skills for Care specifications, within the required timescales. Records are available of the checks carried out by the manager on the competency levels of staff. Further training and update training needs are also identified. The training plan produced since our last visit includes dementia awareness and challenging behaviour as well as health & safety issues such as basic food hygiene and moving & handling. The manager told us arrangements are also being made for staff to receive training in personcentred planning and the mental capacity act. The files we looked at show individual supervision sessions are being provided to staff on a more regular basis. Staff told us they find these sessions useful. Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 24 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. People benefit from the arrangements made for the day-to-day running of the home. A fully comprehensive quality assurance system needs to be implemented in order for people to be fully confident their views are given due consideration as part of the home’s self-monitoring, review and the development of the service. There are procedures in place to promote and protect the heath, safety and welfare of the people who live in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 25 The registered manager has the relevant experience to run a home for this client group. She was previously employed at the home as deputy manager and is in the process of completing the NVQ Level 4 in Care and Management. We have received positive comments about the way the manager runs the home. People who live in the home confirmed to us they are relaxed in her company and staff said she is always available to provide guidance and support. The home does not yet have a fully comprehensive quality assurance system to monitor and assess its own performance. The responsible individual and registered manager are aware of the action they need to take to address this and for an annual development plan for the service to be produced and made available to all interested parties. The home has systems in place to monitor safe working practices within the home, for example the fire records kept include the names of staff and times when staff have participated in fire drills to ensure this is carried out with them at least once every six months. A record is also kept of the names of the people who live at the home that are present during drills to ensure they understand what they should do and identify those who require support in the event of a fire and/or emergency situation. We looked at the information kept about the environment. The records show regular assessments are carried out to ensure people continue to live in a safe environment. The manager told us training in risk assessing is being organised for senior members of the staff team. Records were seen of routine checks carried out by staff, for example the monitoring fridge and freezer temperatures. The home has provided information to show us appliances and equipment are inspected and serviced at regular intervals. Arrangements have been made for the fixed wiring in the home to be checked and for action to be taken to address any areas identified as requiring attention. The manager stated she would forward to us a copy of the report and action taken. There have been not incidents that have required a visit to the Accident & Emergency department of the local hospital. The manager is aware of her responsibility to notify the relevant agencies of any such accident or event which adversely affects the wellbeing of any person living in the home. Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 26 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 Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 X 2 X X 2 X Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action 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 YA1 Good Practice Recommendations The Statement of Purpose and Service User Guide needs to be updated to reflect the changes in registration and the service the home provides. These should be produced in formats that are suitable for the reader. The home should continue its revision of care plans with the individuals who are living in the home. A system should be introduced to ensure a formal review of each person’s care plan takes place at least once every six months with them and people that are significant in their lives. All staff involved in the preparation and serving of food should attend training in basic food hygiene. Procedures should be available for staff to follow where circumstances require medication to be administered away from the home and in the event of a person being prescribed a controlled drug. Additional double sockets should be fitted in two bedrooms DS0000071454.V372323.R01.S.doc Version 5.2 Page 28 2. YA6 3. 4. YA17 YA20 5. Kiniths House YA24 6. YA34 to ensure people who occupy these rooms have the flexibility of safely using their electrical items from a place of their choosing. To ensure the best interests of people living in the home is fully protected the manager should: • request a full employment history, including start and end dates, to be provided on application forms and requests for references 7. YA39 8. YA42 request a written explanation for any gaps in a person’s work history, explore the gaps with the applicant and keep a record of the discussion on the person’s recruitment file A comprehensive quality assurance system needs to be developed to monitor the home’s success in achieving its aims and objectives. This should include feedback to the responses received from people who live in the home and other interested parties and the development of an annual improvement plan for the service. The home should continue to address any action identified in respect of the fixed wiring within the timescales stated by a qualified engineer. • Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kiniths House DS0000071454.V372323.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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