Inspection on 24/01/07 for Knightwell House

This inspection was carried out on 24th January 2007.

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 found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Knightwell House 24/02/06

Knightwell House 03/01/06

Knightwell House 18/11/04

Knightwell House 16/06/04

Knightwell House 24/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Knightwell House 734 Washwood Heath Road Ward End Birmingham West Midlands B8 2JD Lead Inspector Brenda O’Neill Unannounced Inspection 24th January 2007 09:00 Knightwell House DS0000016890.V326336.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 Knightwell House DS0000016890.V326336.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. Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Knightwell House Address 734 Washwood Heath Road Ward End Birmingham West Midlands B8 2JD 0121 327 3623 F/P 0121 327 3623 tracysarmstrong@btopenworld.com 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) Ms Trina Smith Mr Brian Armstrong Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 24th February 2006 Brief Description of the Service: Knightwell House is registered to provide care and accommodation to 13 adults with a learning disability. The home is staffed on a 24-hour basis. Knightwell House is a large three-story building and includes seven single and three double bedrooms. Communal rooms comprise of a small lounge and dining room with an adjoining sitting area. There are toilet and bathing facilities on each floor. The home has limited off road parking. There is a large and well-maintained garden located at the rear of the property. The home is located near to main shopping facilities and main bus service to Birmingham City Centre. Fees at the home are £410.00 per week. Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this key inspection over one day in January 2007. During the course of the inspection a tour of the home was carried out, one staff and two residents’ files were sampled as well as other care, staff training and health and safety records. The inspector spoke with the manager, deputy manager, two visitors to the home and four of the eleven residents. There had been no complaints lodged directly with the home and none had been lodged with the CSCI since the last inspection. What the service does well: Residents at the home had well detailed care plans in place that ensured staff knew their needs and how they were to be met. The plans included very good detail of the residents’ abilities and where staff needed to assist. Residents were encouraged and enabled to make decisions about their everyday lives on an ongoing basis. There was ample evidence that the residents were all treated as individuals and their needs in relation to activities were being met. Many of the residents had been going to the same day placements for a considerable amount of time. Speaking to the residents they were very happy with these arrangements. Some of the residents had very structured days which they preferred others did not. Wherever possible the residents had regular contact with their families and they spoke to the inspector about visiting their relatives and staying with them. The inspector spoke with two relatives who were visiting the home on the day of the inspection. They were very happy about the service being provided at the home. They commented about how relaxed the home was and that they were always made welcome. All residents spoken with were happy with the catering arrangements at the home. They did not take part in the cooking at the home but were encouraged to make their own drinks throughout the day and had access to the kitchen at all times. The menus were decided on a weekly basis after discussions with the residents. The ongoing health care needs of the residents were clearly detailed in their care plans and there was evidence to show that these were monitored and addressed appropriately. Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 6 There were good systems in place for managing residents’ finances ensuring they were protected from abuse. There had been little staff turnover at the home which was very good for the continuity of care of the residents. Most of the staff had worked at the home for a considerable amount of time and relationships between the staff and residents were good. Residents were positive in their comments about the staff. The residents lived in a comfortable, clean and safe environment. 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. Knightwell House DS0000016890.V326336.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 Knightwell House DS0000016890.V326336.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents needs and aspirations are assessed prior to admission to the home to ensure staff could meet them. EVIDENCE: There had been no new admissions to the home for approximately two years and many of the residents had lived there for a number of years. The pre admission assessment process at the home had been assessed at a previous inspection. The findings were as follows: The Statement of Purpose indicated that all service users were invited to the home for an overnight stay. A representative from Knightwell House completed an assessment before admission. One assessment that had been completed showed information pertaining to present and past illnesses, likes, dislikes and other information. Records did not show when the residents had visited the home, or a letter confirming Knightwell House could meet their needs based on the assessment. No requirements had been made in relation to the assessment process and as there had been no new admissions to the home the minor issues raised could not be assessed at this inspection. Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 9 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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans gave detailed information that enabled staff to meet the needs of the residents. Residents make decisions about their lives on a daily basis. Risk assessment practices promote the health, safety and welfare of the service users and support staff. EVIDENCE: Two residents files were sampled. Both files included quite comprehensive care plans. At the beginning of the care plans was a sheet entitled ‘care at a glance’ this gave staff a brief overview of the needs of the residents and indicated if they were fully independent, needed some or full assistance. The plans then went on to detail each of the residents needs in full and what staff assistance they needed or if they were fully independent. All the care plan sheets also indicated if a risk assessment was needed in that particular area of the resident’s life indicating to the reader that they would also need to read the risk assessment. The care plans included some very good detail of the residents’ abilities and where staff needed to assist, for example, the Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 10 maintenance of one resident’s hearing aid and when residents needed supervision when out of the home. Care plans also detailed the residents’ likes, dislikes and preferences, any ongoing health issues and the individual’s preferred daily routines. Also included was detailed information about relationships with families and how contact was maintained. There were care plans in place for any behaviour issues that had been identified. These included the typical behaviour that would be displayed, the possible triggers and how this was to be managed. Risk assessments had been drawn up where appropriate and these detailed where residents were at risk and how the risk was to be managed, for example, when residents were not able to go out alone due to issues around road safety. The manager discussed with the inspector how when new residents are admitted to the home they assess their understanding of road safety by taking people out and seeing how they manage for a considerable amount of time before a decision is made about them going out alone. Social workers were reassessing the needs of the residents on an annual basis to ensure their needs could still be met by the home. The reports for this included no information to suggest the residents had been involved. The manager stated that residents were involved and were asked numerous questions about their care at the home. Staff at the home were reviewing the care plans on a monthly basis but again there was little information included in this and it generally stated ‘no change’. The care plans needed to be formally reviewed every six months. The reviews needed to include the resident and any family or friends that the residents wished to involve. Records of the reviews needed to be kept and the care plans and risk assessments updated as necessary. There was ample evidence that residents were able to make decisions about their lives on an ongoing basis. Where residents were able to come and go from the home on their own this was detailed in their care plans along with their likes, dislikes and preferences. The daily records for the residents evidenced they decided how they spent their time when not at structured day placements, for example, spending time in their rooms listening to their choice of music, deciding what time they got up and when they went to bed and what they had to eat. The residents spoken with were very satisfied that they were able to decide how they spent their time and that if they did not want to do something this would be respected by staff. One of the residents chose not to go out to a structured day placement anywhere and this was understood by staff as he had tried this at various venues and he had determined it was not what he wanted. Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 11 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, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are fully consulted about social and recreational activities; participation depends on the level of interest and abilities. Menu planning and choices are available on a daily basis. EVIDENCE: There was ample evidence that the residents were all treated as individuals and their needs in relation to activities were being met. Many of the residents had been going to the same day placements for a considerable amount of time. Speaking to the residents they were very happy with these arrangements. Some of the residents had very structured days which they preferred others did not. Care plans and daily records showed that residents were attending their day placements as specified and also going out in the evening to clubs. Records also detailed residents spending time with other residents as they wished, spending time in their room listening to music, Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 12 reading newspapers, spending time out of the home with family, taking part in darts matches, going shopping and sticking pictures in scrap books. Many of the residents supported rival football teams and this was evident in their bedrooms by the duvet covers and pictures on the walls. Visits to watch the appropriate football matches were enabled wherever possible. Residents also spoke about their holidays and it was evident that some preferred to go abroad others liked to holiday in England. Residents accessed facilities in the local community on a regular basis including health care facilities and shops. Many of the residents were also able to use public transport independently. One of the residents spoke to the inspector about his dislike of public transport so he walked to his day placement. Wherever possible the residents had regular contact with their families and they spoke to the inspector about visiting their relatives and staying with them. There were some very strong friendships in the home as some residents had the same interests. Two residents had requested to share a room and one of them spoke to the inspector about how the manager was trying to facilitate this. The inspector spoke with two relatives who were visiting the home on the day of the inspection. They were very happy about the service being provided at the home. They commented about how relaxed the home was and that they were always made welcome. They also stated that their relative seemed very content at the home and that they were always informed if he was unwell. All residents spoken with were happy with the catering arrangements at the home. They did not take part in the cooking at the home but were encouraged to make their own drinks throughout the day and had access to the kitchen at all times. The menus were decided on a weekly basis after discussions with the residents. Staff were aware of the likes and dislikes of the residents and these were detailed in their care plans. The main meal of the day was in the early evening during the week as most of the residents were out during the day. Those who were at home on the day of the inspection had a light lunch of sandwiches and yoghurt. At weekends the main meal of the day was at lunchtime as this was what the residents preferred. Breakfast was usually toast and cereals during the week but at weekends the residents had cooked breakfasts, as again this was what they wanted. The food records being kept evidenced that the residents were receiving a varied and nutritious diet. Healthy eating was encouraged as much as possible. One of the residents was diabetic and he spoke to the inspector about his diet and he was well aware of what he should and should not eat. Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 13 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s personal and health care needs were met in way that suited them. Medicine management had improved and safe guarded the residents. EVIDENCE: Residents’ needs in relation to personal care were minimal. Most were able to manage their own needs with only prompting from staff. Where assistance with personal care was needed this was detailed in the appropriate care plan, for example, some residents needed help with shaving and this was clearly detailed. During the course of the inspection one of the residents went and had a shave after being reminded by a member of staff, another spoke about staff reminding him to have a bath. The ongoing health care needs of the residents were clearly detailed in their care plans and there was evidence to show that these were monitored and addressed appropriately. The files sampled had a list of each health care appointment that the residents had attended and then there was a separate sheet detailing the reason for the visit and the outcome. One of the residents had an ongoing problem with his ears and the records clearly showed this was Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 14 being attended to. There were records detailing each visit to the doctor, chiropodist, dentist and optician. Residents also saw other health care professionals as necessary, for example, psychiatrists and community psychiatric nurses. There were records on individual files that indicated residents were weighed on a monthly basis. Speaking to the manager it was evident that the residents were all keeping quite well on an ongoing basis. Medication at the home was administered via a Nomad monitored dosage system over seven days. The system was well managed and had improved since the last inspection. All the requirements made following the last inspection had been met. Prescriptions were seen, checked and photocopied prior to them going to the pharmacist. The quantities of all medicines being received into the home were being acknowledged on the MAR (medication administration record) charts. The manager had also drawn up extensive policies and procedures for the management of medication in the home. Two minor issues were raised at this visit. One resident had recently had a painkiller prescribed. This was not included in the monitored dosage cassettes and the quantity being held at the end of the last MAR chart had not been carried forward to the current one, therefore it was difficult to audit. It was also noted that the home had paracetamol as a homely remedy and although when this was administered it was appropriately recorded there was no running balance of what was held in the home. The manager needed to ensure that there was a complete audit trail for all medication held in the home. The other boxed medication that was audited was correct. There was no controlled medication being administered at the time of the inspection. Staff had all received basic training for handling medication and at the time of the inspection were undertaking more in depth training from a college. Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 15 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was an appropriate complaints procedure in place. Residents’ views were listened to and acted on. The policies and procedures in place and the training staff received ensured the residents were protected from abuse. EVIDENCE: There was a copy of the complaints procedure on each of the residents’ files seen. The home had not logged any complaints since the last inspection and none had been lodged with the CSCI. Residents were very comfortable in the presence of the manager and the deputy at the home and there was no doubt that they would raise any issues with them. It was evident from the residents meeting minutes that they were listened to. Speaking to the manager it was also evident that he felt the residents had other avenues that enabled them to raise any concerns, for example, staff at day placements, key workers and relatives. There were procedures on site for the prevention of abuse. These were viewed at the last inspection and found to be appropriate. Staff had received training in the prevention of abuse and managing challenging behaviour. No issues in relation to adult protection had been raised at the home since the last inspection. The systems in place for helping the residents to manage their money were assessed. The manager was the appointee for all the residents. Although this was not an ideal situation it had been a long standing arrangement and was Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 16 the only way residents could be guaranteed access to their money on an ongoing basis. The records held at the home were sampled. All the residents had their own post office savings accounts and records of the income and expenditure from these were being kept. There were some amounts of cash being kept in the home for the residents and separate records for these were kept. All residents had individual tins and books. The records showed all income and expenditure and where money had been banked into the post office accounts. There were receipts available for all expenditure and where residents received cash they had signed for this. All the cash balances checked were correct. Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 17 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, 25, 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents lived in a comfortable, clean and safe environment. EVIDENCE: There had been no changes to the layout of the home since the last inspection. The home was comfortable, safe and generally well maintained. The accommodation at the home is over three floors. As there are no lifts at the home it would not be appropriate for anyone with mobility difficulties. Bedrooms are located on all three floors and are a mix of singles and doubles. None of the bedrooms have en-suite facilities but all have wash hand basins. The bedrooms varied in size and although some were quite small they were very personalised to the occupants’ choosing and comfortable. All residents spoken with were happy with their bedrooms. Many of the rooms were themed to the occupants’ favourite football team. There were no locks on the bedroom doors but there was evidence on the residents’ files that they had been Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 18 consulted about this and did not want locks. The furnishings, fittings and decor in the bedrooms were of an acceptable standard. The home had adequate bathing, toilet and showering facilities. There is a shower and toilet on the ground and second floors and a bathroom and toilet on the first floor. The bathroom and toilet were quite run down and in need of refurbishment. This was discussed with the manager who stated this was planned to be carried out when the residents were on holiday. Communal areas comprise of a large lounge and a dining room that also incorporates some additional comfortable seating if residents wish to sit in there. Both rooms were adequately furnished and decorated. The home also has a large modern kitchen that residents had access to at all times. The garden at the rear of the home provided ample outdoor space for the residents. The home had an emergency call system so that residents could alert the staff member sleeping in if they were required. There were no other specific aids and adaptations as the current resident group did not require these. The washing machine was housed in the kitchen but the inspector was informed it was only used for personal laundry as linen was sent out to a laundry. The home was clean and hygienic throughout on the day of the inspection. Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 19 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 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate staffing levels were being maintained by a stable staffing team. Induction training needed to be improved to ensure staff were equipped with all the necessary skills and knowledge to care for the residents. Recruitment procedures needed to be improved to ensure the residents were safeguarded. EVIDENCE: There had been little staff turnover at the home which was very good for the continuity of care of the residents. Most of the staff had worked at the home for a considerable amount of time and relationships between the staff and residents were good. Residents were positive in their comments about the staff. Staffing levels at the home were varied according to the needs of the residents. Levels were reduced during the weekdays as the majority of the residents were out. There were always three staff on duty during the busy morning period, two people on duty during the evening and one member of staff sleeping in. Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 20 One new staff member had been appointed since the last inspection. The recruitment records for this person were sampled. There was a completed application form, proof of I.D. and a completed medical questionnaire. There were two written references but both were dated after the person had commenced employment. There was evidence that a CRB check had been carried out but this had not been obtained prior to employment starting and there no evidence of a POVA first check. This was discussed with the manager and he was advised that to ensure the protection of the residents all the required checks must be carried out prior to staff commencing their employment. The new staff member had undertaken some induction training however this was signed as completed within one week of starting employment. The manager had purchased some induction training books that complied with the requirements laid down by Skills for Care for induction training. He informed the inspector that all staff were to undertake this training. The manager needed to ensure that all future employees received induction training in line with these specifications within twelve weeks of starting their employment. The training records for staff were sampled and these showed staff had undertaken training in such topics as food hygiene, manual handling, first aid adult protection and managing challenging behaviour. The majority of the staff had achieved NVQ level 2. It was strongly recommended that a training matrix was developed for the home to make it easy to track what training had been undertaken by staff and when it was due to be updated. Staff were undertaking medication training at the time of the inspection as a distance learning course facilitated by a local college. Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 21 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 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was generally well managed however some issues needed to be addressed to ensure the safety of the residents and the staff. The home needed to have a yearly development plan in place based on seeking the views of the residents. EVIDENCE: The manager had been employed at the home for a number of years and demonstrated a good knowledge of the residents in his care and the running of a residential home. The manager stated he had completed his NVQ level 4 in care and management. The residents were very comfortable in his presence and friendly relationships were evident. Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 22 A quality audit had been carried out at the home in March 2006 and a record of this was on site. There were some actions detailed at the end of the audit. However no development plan had been drawn up from this. There was no question that the residents’ views were considered at the home. Being quite a small home the manager and staff had a lot of contact with the residents and there were also documented residents meetings which generally took place on a monthly basis. The owner of the home was visiting every two months and completing the required reports on the conduct of the home however the required frequency for these is monthly. These visit reports would also contribute to the quality monitoring system in the home. Health and safety of the residents and staff were generally well managed. Staff had received training in safe working practices. There was evidence on site that the majority of the equipment had been serviced as required including the fire alarm, emergency call system, portable electrical appliances and gas appliances. All the in house checks on the fire system were up to date and fire drills were being carried out every six months. There was no evidence on site that staff had undertaken recent fire training. The fire officer had made a requirement at a visit in April 2006 about smoke seals being fitted to doors and this had not been met. It was also noted that the electrical wiring inspection certificate was out of date and this needed to be addressed. The environmental health officer had visited the home since the last inspection and had stated ‘there were very good practices in place. Knightwell House DS0000016890.V326336.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 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 X 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 3 26 X 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 24 No. 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 YA6 Regulation 15(2)(b) Timescale for action Care plans must be reviewed and 01/04/07 updated as necessary as a minimum every six months. Records of the reviews must be kept and included evidence of where the residents have been involved. The balances of any medication remaining in the home at the end of the MAR charts must be carried forward to the next MAR chart. A running balance must be kept of any homely remedies in the home. The bathroom and toilet on the first floor must be refurbished. Prior to new staff commencing employment the registered person must ensure: Two written references have been obtained. A POVA first check or CRB check has been obtained. The registered person must ensure that staff undertake DS0000016890.V326336.R01.S.doc Requirement 2. YA20 13(2) 14/02/07 3. 4. YA27 YA34 23(2)(b) 19 schedule 2(5)(8) 01/06/07 01/03/07 5. YA35 18(1)(a) 01/03/07 Knightwell House Version 5.2 Page 25 6. YA36 18(2) induction training in line with the specifications laid down by Skills for Care and completed within the given time scale. Supervision of staff must be fully implemented. (Previous time scale 01 February 2006 partly met. Time scale of 01/04/06 not assessed at this visit.) The home must have an annual development plan based on seeking the views of the residents with a view to improving the service. The registered provider must ensure a visit to the home is carried out every month and that a report is completed on the conduct of the home. Staff must have their fire training updated. The requirement made by the fire officer must be addressed. The registered person must ensure the electrical wiring in the home is inspected for safety. 01/04/07 7. YA39 24(2)(3) 01/05/07 8. YA39 26 01/04/07 9. 10. 11. YA42 YA42 YA42 23(4)(d) 13(4)(c) 23(2)(c) 01/03/07 01/04/07 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA35 Good Practice Recommendations It is recommended that a staff training matrix is developed to enable easy tracking of what training has been undertaken by staff and when it is due to be updated. Knightwell House DS0000016890.V326336.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Knightwell House DS0000016890.V326336.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. 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