Inspection on 16/10/06 for Knights Luxury Retirement Home

This inspection was carried out on 16th October 2006.

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

Knights Luxury Retirement Home 22/07/08

Knights Luxury Retirement Home 13/08/07

Knights Luxury Retirement Home 17/01/06

Knights Luxury Retirement Home 06/07/05

Knights Luxury Retirement Home 30/09/04

Knights Luxury Retirement Home 11/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Knights Luxury Retirement Home 365/367 Clifton Drive North St Annes On Sea Lancashire FY8 2PA Lead Inspector Denise Upton Unannounced Inspection 16th October 2006 09:00 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 Knights Luxury Retirement Home DS0000009758.V311877.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. Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Knights Luxury Retirement Home Address 365/367 Clifton Drive North St Annes On Sea Lancashire FY8 2PA 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) 01253 720421 01253 782037 Aegis Residential Care Homes Limited Jean Kilburn Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 31 service users to Include:*Up to 31 service users in the category of Op (Old age not falling within any other category). 17th January 2006 Date of last inspection Brief Description of the Service: The Knights Retirement Home is one of a number of homes owned and operated by Aegis Residential Care Homes Limited. The home is registered to accommodate up to 31 older people who do not require nursing care. The Home is a none smoking establishment that is clearly identified in the written information provided to service users and prospective service users. The Knights Retirement Home is a detached property located on a main thoroughfare of St Annes and conveniently situated in close proximity to the main shopping centre, community facilities and resources and the promenade. Communal areas of the home are comfortably furnished and allow for activities to be undertaken in one area of the home while providing a quiet area for those who do not wish to participate. The majority of service users are accommodated in single bedroom en-suite accommodation except for individuals who have made a positive choice to share twin accommodation. There is a passenger lift to access all areas of the internal environment and a ramped access to the front of the building. Although the home does not provide garden areas, there is a public park in close proximity that service users can access with ease and a patio area to the front of the property that is provided with seating to enable service users to sit out in the summer months. Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit took place during the course of a mid-week day and spanned a period of eight and three quarter hours. Twenty-one core standards of the thirty-eight standards identified in the National Minimum Standards-Care Homes For Older People were assessed along with a partial reassessment of one requirement and recommendations identified in the last inspection report. The inspector spoke with the registered manager, the company’s Operations and Marketing Director, the cook on duty and a senior carer. In addition, two individual groups of service users living at the home were spoken with in lounge areas and four service users were spoken with individually in their bedroom accommodation. A number of records were also examined and a partial tour of the building took place that included communal areas of the home and some bedroom accommodation. Information was also gained from a pre inspection questionnaire completed by the registered manager. In addition a number of service users also completed a Commission for Social Care Inspection service users comment card that helped to form an opinion as to whether service users needs and requirements were being met. Currently the cost of residential care fees at The Knights Care Home range between £320 00 - £580 00 per week. What the service does well: The home has a group of staff that are enthusiastic and work well together to provide a good quality of care for service users that live there. Service users spoken with were comfortable living at the home and got on well with the staff team. Routines within the home are flexible to make sure that the people who live there can enjoy the lifestyle they have chosen for themselves that includes social activities and outings. Service users are encouraged to have their say and are involved in making decisions about how they would like the home to be run through a variety of ways that includes resident forums, daily discussion with staff, a monthly news letter and a questionnaire. The home has good systems in place to make sure that service users are kept safe. The health needs of service users are well met with evidence of a good working relationship with medical staff such as the district nurses and doctors who visit the home. Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 6 Service users felt that their privacy and dignity were well respected and the home has a wide variety of activities made available for service users to enjoy. Meals are varied, well balanced and nicely presented offering choice and variety. All service users spoken with were very pleased with the variety and choice of the meals served. All service users spoken stated that they were pleased with the standard of decoration and furnishings in the home and felt that the home was very comfortable and well maintained. 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. Knights Luxury Retirement Home DS0000009758.V311877.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 Knights Luxury Retirement Home DS0000009758.V311877.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): 3 Quality in this outcome area is adequate. The pre admission assessment information to identify what the prospective service user can do well and what help may be required could be more detailed. This should clearly highlight if current needs, wants and wishes could be met at the home including social, religious and cultural requirements. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are only admitted to the home following a pre admission assessment of the prospective service user’s current strengths and needs undertaken by the registered manager. However the information obtained during the pre admission process could be more detailed and take into account the individual’s social, religious and cultural needs and requirements. In some instances, to supplement the home’s independent assessment, further information is made available through a health and/or social services multi disciplinary assessment that provides further information regarding the Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 9 prospective service user. This collated information enables the registered manager to make an informed decision as to whether The Knights Retirement Home could satisfactorily address the prospective service user’s current strengths, needs, wants and wishes. The information obtained then forms the basis of the initial plan of care. One of the service users spoken with individually confirmed that this process had been undertaken in respect of their admission to The Knights Care Home and stated that the staff had been helpful and welcoming through the pre admission and admission period. A further recently admitted service user stated that her family had been involved in the assessment process and that a contract of residency had been agreed and signed. Knights Luxury Retirement Home DS0000009758.V311877.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 & 10 Quality in this outcome area is adequate. There is a care planning system in place to provide staff with the information they need to meet service users needs. However, although information is recorded the actual care plan should be more detailed. The health care needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication in this home is well managed promoting good health. Personal support is provided in such a way as to promote and protect service users’ privacy, dignity and independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the course of the inspection, four recently admitted service users were ‘case tracked’. This involves looking carefully at all the information that is kept by the home regarding the pre admission assessment of these people and the Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 11 assistance and support required to ensure that the service users needs and requirements are met. The care plans observed in respect of the service users ‘case tracked’ were not always consistent. Whilst on one service user care plan there was good detail of an identified risk and how this could be minimised, other care plans observed did not contain similar information. One care plan identified that a service user required bed rails however there was no evidence of a formal risk assessment to identify why this piece of equipment was required or if an alternative protective measure had been considered. A routine risk assessment regarding the prevention of falls indicated that another service user should be ‘supervised at all times’ but there was nothing to indicate the cause of the falls, or how they could be minimised or eliminated. Another section of the care plan that highlighted ‘numeracy’ skills stated ‘not too bad’ but gave no indication of how this had been assessed. A further example was under the section, ‘expressing sexuality’ where it was recorded ‘fine’, again without explanation. However where there was an identified need for incontinence pads there was no indication of whether assistance was required or if the service user was self-caring in this task. In the main, care plans evidenced were sparse and lacking detail with particular reference to social, religious and cultural needs and requirements. One care plan stated that a particular service user enjoyed typing, but there was no indication of how this person was enabled to enjoy this activity. Likewise, one Health and Social Services professional pre admission assessment stated that the particular service user required prompting with personal hygiene and dressing. However the care plan did not indicate this stating the service user was ‘fine’ but did not indicate ‘fine’ for what. It is essential that care plans are easy to read, up to date, comprehensive and clearly identify exact requirements, wants and wishes. Each key worker should be familiar with the content of the individual care plan and not rely on verbal information sharing. It is recommended that the care planning records are completed in full and where an assessment of a particular section has not been undertaken, this should be indicated rather than a statement being made that is not the outcome of a thorough assessment process. It was also noted that care plans had not been formally reviewed on a monthly basis. It important that all care plans are regularly reviewed and brought up to date as required to enable staff to have the relevant information to provide the level of individual care and support required. Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 12 It was evidenced through discussion with staff and service users and observation of records that service users health needs are fully met. There is a good relationship with health and social care professionals in order to maintain health and social well-being. Service users spoken with all confirmed that they felt well cared during periods of ill health with one service user stating “ the staff were very good, wonderful, when my foot was bad”. All service users who wish to and have capacity to do so are enabled to selfadminister their own prescribed medication within a risk assessment framework. Medication is securely stored and all staff with responsibility for medication administration are required to adhere to the procedures for the receipt, recording, storage, handling, administration and disposal of medication. It was noted that the recording of a recent prescription into the home for a controlled drug had been inaccurate. This had been self-identified by the management team and immediate action taken to address the matter. The maintenance of service user privacy and dignity is given high priority at The Knights Care Home that was strongly reinforced by every service user spoken with. The topics of privacy and dignity form part of the induction training programme and a number of staff have also completed a three-month ‘Equality and Diversity’ course that also incorporated issues of privacy and dignity. Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 13 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 & 15 Quality in this outcome area is good. Links with family, friends and the community are positively encouraged and support the ‘in-house’ social activities that are arranged. This enriches service users social opportunities. Dietary needs of service users are well catered for with a balanced and varied selection of foods available that meets service users taste and choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the course of the inspection it was observed that the routines of daily living and activities remain flexible and varied to meet individually assessed needs. Service users are enabled to exercise choice in all aspects of their daily life that was confirmed through discussion with several service users. Social relationships are encouraged either through family/friends visiting at a time of the service users choice or social stimulation in the wider community. A wide variety of `in-house` activities are also available coordinated by a designated social care co-ordinator with specific responsibility for arranging Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 14 social events. Recent activities including tai chi, coffee mornings, a fancy dress Halloween party, trips out in the home’s mini bus, resident’s forums, quiz’s, bingo, a monthly tea party and film shows with nibbles. One service user individually spoken with stated that she had “enjoyed the tea party very much” Social interaction and independent activity in the wider community is also encouraged. There is also regular communal worship that takes place in the home for service users who wish to participate. Service users at the Knights Care Home are also provided with a monthly newsletter, which incorporates the Managing Director and Care Manager’s comments, contributions from service users, birthdays and celebrations, comings and goings of service users, a quiz and the monthly activities schedule. As previously stated in this report, the individual social interests of service users should be clearly recorded on their care plan with detail of how their interests are to be enabled and provided within the home. All service users are encouraged to maintain control of their own financial affairs for as long as they wished to or be assisted in this task by their family or advocate as confirmed by several service users spoken with. Information regarding the local advocacy service is made freely available for service users and their relatives in communal areas of the home to enable them to access independently if required. From observation and discussion, it was evident that service users are encouraged to bring some of their own possessions with them into the home to make their individual bedroom feel more homely and comfortable. Meals and mealtimes at The Knights Care Home are given high priority with a varied and balanced menu provided that is designed round the known likes and dislikes of service users living at the home. Specialist diets in respect of religious, cultural or medical need can be accommodated and as observed, hot and cold drinks and snacks are made available throughout the day. Service users spoken with were very positive in their comments regarding the quality and variety of the meals served. During the course of the visit the lunchtime meal was observed. It was noted that the interaction between staff and service users was good with staff sensitive to individual needs and requirements. Discussion with the cook on duty and individual service users confirmed that a wide variety of foods are served and menus are determined during the resident’s forums. Fresh fruit and yoghurt are available every day and the cook on duty always speaks with service users at the end of every meal to ensure they had enjoyed the meal served, which assists the internal quality audit. Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 15 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 & 18 Quality in this outcome area is good. The home has a satisfactory complaints system with evidence that service users feel their views are listened to and acted upon. Staff receive training in respect of adult abuse issues that helps protect service users from potential abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Knights Care Home has a comprehensive corporate complaint policy and procedures, which outlines the home’s commitment to resolving complaints within 28 days. The complaints procedure is incorporated in the Statement of Purpose and Service Users Guide to inform service users and their relatives how to make a complaint should the need arise. A service user spoken with stated she would have no hesitation about speaking with the registered manager if she had a concern and felt confident that any concern would be taken seriously and acted upon. Since the last inspection two complaints were received by the home that were both substantiated. Both complaints were investigated with a record kept of the method of investigation, outcome and any action required as a result of the investigation. Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 16 The Knights Care Home has available a variety of policies and procedures for the protection of service users. These include an Adult Protection Policy based on the ‘No Secrets In Lancashire’ document that helps to protect service users from abuse or discrimination and a whistle blowing policy to inform staff of their responsibility in respect of any suspect abuse. Policies have also been developed in respect of service users monies, gifts, wills and aggression. Any items held for safekeeping are secured in a locked environment with appropriate records kept. Staff have now completed a distance learning course in respect of adult abuse and the protection of vulnerable adults. Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is excellent. The standard of the environment within this home is very good and provides service users with an attractive, homely and well-maintained place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service Users at The Knights Care Home live in very well maintained accommodation that is domestic in character and has been designed to meet the individual and collective needs of service users accommodated. The home is conveniently situated close to the town centre and local community resources and facilities. There is a raised patio area to the front of the home that is provided with seating that service users can enjoy in the summer months and a ramped access facility for those who have restricted mobility. Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 18 The layout of the home gives service users opportunity to move freely round the building and access all areas with ease. The home is a none smoking home that is well maintained, tastefully decorated and offers alternative lounges and a large dining room There is a passenger lift to access bedroom accommodation located on the first and second floor of the building. Service users spoken with were very complementary regarding the communal space and their individual bedroom accommodation. However it was noted that a small number of bedrooms doors have yet to be provided with an appropriate lock to ensure privacy for the occupant. From discussion with the registered manager it is understood that plans are in place to ensure that all bedroom doors are provided with an appropriate locking mechanism by December 2006. It is also understood that redecoration of the lounge/dining room is to take place in the near future. Fresh flowers were displayed in the lounge areas courtesy of a local church. Service users have choice of the colour and style of their individual bedroom and can also personalise their private accommodation with personal items of furniture that is agreed prior to admission. Policies and procedures have been developed to ensure the home is clean, pleasant and hygienic and adequate measures are taken for the control of infection. A number of service users spoken with individually commented on the cleanliness of the home and felt that a good standard of accommodation was been provided. As identified in the last inspection report, the walls and floor of the laundry area, sited in the basement of the home, require some attention to ensure they are kept in good order and readily cleanable. Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 19 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 & 30 Quality in this outcome area is good. There is a good match of well-qualified staff offering consistency of care within the home. The arrangements for nationally recognised NVQ training are good with staff demonstrating a clear understanding of their roles. The vetting and recruitment practices of the home are good, which helps to protect service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a good mix of staff that are committed to offering consistency of care and who are pro-active in undertaking a variety of training initiatives. Additional staff are on duty a peak times of activity during the waking day and there are sufficient ‘waking watch’ staff on duty at night to ensure service users needs are adequately addressed. Staff and service users spoken with all stated that they felt there is enough staff on duty at any given time to make sure that people receive the level of care required. Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 20 Domestic staff are also employed in sufficient numbers to ensure that standards relating to food, meals and nutrition are fully met and that the home is maintained in a clean and hygienic state. Since the last inspection further members of the care staff team have successfully achieved a National Vocational Qualification (NVQ) in care. At present 8 of the 15 members of care staff have achieved Levels 2, 3 or 4 of this award and currently three further members of staff are waiting to commence NVQ Level 4 and a further four members of staff are completing Level 3 of this award. In addition, a number of none care staff are planning to undertake an NVQ qualification in business and administration and domestic care. The staff group also undertake a variety of other ‘short course’ training opportunities relevant to their role. The recruitment of staff at The Knights Care Home follows a consistent approach. Observation of three recently appointed staff personal files confirmed that all the required references and clearances had been obtained and deemed to be satisfactory. However although verbally confirmed, it was not possible to confirm from the documentation held that the Criminal Record Bureau (CRB) clearance had been received prior to the applicant actually taking up post at the home. It is essential that the full CRB clearance certificate sent to the home be held until the next inspection takes place to enable the inspector to observe the document. Following this, the full CRB clearance certificate can be destroyed although a brief record should be made of the date the clearance was requested and received and if the clearance was satisfactory. There was evidence on the staff files examined of completion of the ‘Skill for Care’ induction standards and previous training certificates that had been obtained through alternative employment elsewhere. Service users spoken with were positive in their comments with regard to the support of the registered manager and staff group with one service user stating, “the staff are all very good”. Another service user commentated that “staff are good, kind and helpful but they don’t stand any nonsense” and a third service user informed the inspector that, “everything here is very good, I am happy with everything, we are very lucky to be here”. It was clearly evident from observation that there is a good rapport between service users and staff that helps to create a supportive and caring environment. Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 21 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 & 38 Quality in this outcome area is good. The registered manager is well qualified and well supported by the senior staff in providing clear leadership throughout the home. The systems for service user consultation are good with a variety of evidence that indicates service users’ views are sought and acted upon. Staff training, policies and good practice promote the health and safety of those living and working at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 22 Since the last inspection a new registered manager has been appointed at The Knights Care Home. The person appointed is very experienced and well qualified in managing a care home for older people. The new registered manager has achieved an NVQ Level 4 qualification in care and management, The Registered Managers award, BETC introduction to management qualification and has completed a wide variety of other courses relevant to the care of older people. Regular staff meetings and supervision sessions take place in respect of all staff. Quality assurance in this home is well managed. There is a range of external and internal quality monitoring systems in place and The Knights Care Home has achieved the Investors in People Award. There are clear lines of accountability within the home and external management. Internal systems that include resident’s forums, monthly newsletter, informal discussion, staff meetings and supervision take place on a regular basis. In addition, the organisation provides a quality assurance questionnaire on an annual basis that can be completed by service users and/or their family. The outcomes of service user questionnaires are returned to the company’s registered office, analysed and results referred back to the home’s manager for action. The outcomes of service user questionnaires are made known to service users/other stakeholders in the monthly newsletter. A service user spoken with confirmed that she was, from time to time, asked how she felt about living at the home and that service users views and opinions are taken into account. Service users financial interests are safeguarded by the financial procedures adopted by the home. All service users, wherever possible, are encouraged to remain financially independent or assisted in this task by a family member. As observed during the course of the inspection, when the home does retains monies or valuables in respect of a service user, this is accurately recorded and secure facilities are provided for the safe keeping of monies and valuables held on behalf of the service user. The Knights Retirement Home has available a variety of policies and procedures to ensure the health, safety and welfare of service users, visitors and members of staff. At the time of inspection various records, maintenance records and certificates relating to equipment and instillations were examined and found to be up to date and in good order. All members of the care staff team receive mandatory health and safety training covering a variety of topics. In addition, risk assessments are available in respect of fire, health and safety issues that are regularly reviewed. Updated health and safety training is planned and there a qualified first aider on duty at all times. Knights Luxury Retirement Home DS0000009758.V311877.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 CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Knights Luxury Retirement Home DS0000009758.V311877.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. 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 2 Refer to Standard OP3 OP7 Good Practice Recommendations The pre admission assessment document should be more detailed to provide a holistic account of current strengths and needs. Service user care plans should be further developed to provide staff with a detailed account of all strengths, needs, wants and wishes and the action needed to fulfil these requirements. Risk assessments should be routinely completed when a risk has been identified with significant outcomes incorporated in the care plan. All care plans/risk assessments should be routinely reviewed on at least a monthly basis. All individual bedroom accommodation should be provided with an appropriate locking mechanism to protect the privacy of the individual. Attention should be given to the laundry area to ensure DS0000009758.V311877.R01.S.doc Version 5.2 Page 25 3. OP24 4. OP26 Knights Luxury Retirement Home 5. OP29 surfaces remain readily cleanable. The full CRB disclosure should be retained by the home until the next inspection has taken place. Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Knights Luxury Retirement Home DS0000009758.V311877.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!