Inspection on 22/02/07 for Kynance

This inspection was carried out on 22nd February 2007.

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

Kynance 01/10/08

Kynance 14/02/06

Kynance 14/09/05

Kynance 01/02/05

Kynance 11/06/04

Kynance 04/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Kynance 97 York Avenue East Cowes Isle Of Wight PO32 6BP Lead Inspector Neil Kingman Unannounced Inspection 22 February 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kynance DS0000012505.V325803.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. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kynance Address 97 York Avenue East Cowes Isle Of Wight PO32 6BP 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) 01983 297885 01983 297885 Mentfade Limited Corinne Rachel Lovejoy Care Home 24 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (24), of places Physical disability over 65 years of age (1) Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user in category DE may be accommodated over the age of 60 years 14 February 2006 Date of last inspection Brief Description of the Service: Kynance residential care home provides care and accommodation for up to 24 older people, with capacity for six people in the dementia care category, and one person with a physical disability. The single room accommodation is arranged over two floors, with access to the first floor via a three-person passenger lift. Currently all but one room has an en-suite facility. The home is situated in a residential area of East Cowes, on the main road leading to, and about a quarter mile from the town centre. An ongoing maintenance and refurbishment plan is in place to ensure the home continues to provide a safe, comfortable and homely environment. At the time of this inspection building work was in progress to extend the home and provide additional accommodation and facilities. Communal areas comprise a lounge, dining room and conservatory on the ground floor, and a quiet lounge on the first floor. Each floor has access to communal bath/shower and toilet facilities. A mini bus is available to provide regular outings for the residents. The home provides 24 hours staffing. Weekly fees are £361.91 plus attendance allowance where applicable. The manager states that a copy of the home’s service user’s guide is provided to all residents or their representatives where applicable. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the results of an evaluation of the quality of the service provided by Kynance and brings together accumulated evidence of activity in the home since the last key inspection on 14 February 2006. Part of the process has been to consult with people who use the service; including a telephone discussion with a social services care manager. There were fourteen responses to the visitors/relatives survey and one from a resident in the home. Included in the inspection was an unannounced site visit to Kynance by an inspector on 22 February 2007. The registered manager Mrs Lovejoy was on duty and available throughout the day, and the proprietor was present during the morning. During the visit the inspector spoke with staff on duty, several residents as a group and others in the privacy of their rooms. In addition, there was an opportunity for the inspector to speak with a Community Nurse and four relatives who were visiting the home at the time. The inspector toured the building with the proprietor and looked at a selection of records. The majority of responses from the consultations were very positive. What the service does well: In common with the outcomes of the last two inspections of Kynance the home continues to provide a good quality service for the people who live there. The majority of visiting relatives were full of praise for all aspects of the home. One comment from a visitor was, “The home from my experience of visiting the elderly is one of the best here in the area; clean, fresh, presentable and has very caring staff.” Another continued the theme; “The residents of Kynance are very fortunate to be living in Kynance in their twilight years. The manager and all staff are second to none.” There was continued evidence of an improving service, with the proprietor investing in further development for the overall benefit of the residents. The manager ensures that standards are maintained through ongoing training and development of staff, and systems to ensure the needs of the residents are met. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 6 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. Kynance DS0000012505.V325803.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 Kynance DS0000012505.V325803.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 and 6 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager ensures that the care needs of the people who live at Kynance will be met by undertaking a proper assessment prior to them moving into the home. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. EVIDENCE: Pre-admission assessment Service users should know that their needs will be met when they move into a home. An important part of ensuring this happens is the pre-admission assessment process. It had been noted at previous inspections of Kynance that this standard had been met. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 9 During this site visit the manager explained that she always undertakes a preadmission assessment of a prospective resident’s needs. The home’s service user’s guide makes clear that emergency admissions are not normally accommodated unless a pre-admission assessment can be carried out. The inspector looked at how the home managed the admission of the newest resident, who moved into the home during January 2007. Records showed, and the manager confirmed that she undertook a full pre-admission assessment of the individual’s needs at the hospital, and recorded the information on an assessment form, which was then used to form the basis of their personal care plan. A copy of the assessment was available on the resident’s file. Intermediate care Residents at Kynance tend to be long term. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. However, respite care is provided, if there is a room available. There was no evidence that this arrangement had any negative impact on the existing residents. Kynance DS0000012505.V325803.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 and 10 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a system of care planning with an individual plan for each resident. They provide a good demonstration that residents’ health and social care needs are identified and met and include risk assessments and monthly reviews. The home promotes and maintains residents’ healthcare and ensures that access to healthcare services is available at all times. Medication is securely held and appropriate records maintained. The home ensures that staff respect residents’ privacy and dignity at all times, especially with regard to the arrangements for health and personal care. EVIDENCE: Care planning – The home has a system of care planning with an individual personal plan for each resident. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 11 The manager explained that the home had changed the care planning format in December last year to a more flexible and ‘user friendly’ system. The inspector looked at a sample of three plans. The intention was to look at the outcomes for residents in general by assessing all areas of care for those sampled. The sample included the newest admission to the home, a resident whose care needs included the additional involvement of the Community Nurse, and a resident who had lived at Kynance for about six years, was largely self-caring and able to go on short walks alone outside the home. The inspector took account of the change in systems and noted the care plans in the old format were readily available. Plans were noted to be clear, comprehensive and flexible, in that additions can be made according to individual needs. Information in the plans is generally well recorded. Each resident’s plan includes key information: • • • • • • • • • General information about the resident, including special needs. Pre-admission assessment. Promoting independence. Daily routines and preferences. Activities and interests. A range of assessments tailored to the individual resident. Manual handling and specific risk assessments. Care plan reviews. Daily recording of relevant information. The inspector spoke with staff on duty, including the deputy manager. The consensus was that the new care planning system had taken some getting used to but was more flexible and user friendly than the one they had used for some years There were positive comments from a social services care manager who confirmed that staff followed and regularly reviewed residents’ personal plans, although the new system had not yet been seen. There was a mixed reaction from residents when the inspector asked them about their individual care plans. Responses varied from those who were confused about the existence of such a document to those who were well aware of their care plan. One said they new about their plan but were not really interested. Two visitors to the home said they were well aware of their relatives care plan. They and thirteen of the fourteen responses to a survey indicated they were kept informed of all important matters affecting the respective resident’s health and welfare. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 12 Health and access to care services The manager confirmed, and records evidenced the regular contact with GPs, optician, dentist, community nurse etc. Residents spoken with said that the home looked after their health needs very well. During the site visit the inspector had an opportunity to speak with two visitors who said they were very happy with the way the home took care of the residents’ medical and health needs. It was clear during the discussions that a range of health care professionals had been consulted about this particular resident’s needs. In discussions with the manager and staff it was confirmed that one resident had a pressure sore that was regularly dressed by the Community Nurses. The home has a range of equipment for the management of pressure areas. It is used with a minority of residents who are vulnerable to pressure sores. The manager said, and care records confirmed that local policy was that one GP is assigned to the home from the East Cowes Health Clinic and attends all residents. The manager said that while all residents were generally happy with the arrangement the home would endeavour to accommodate a different GP of choice wherever possible. Thirteen of the fourteen responses to a visitors/relatives survey indicated they were satisfied with the overall care provided. Medication Medication is dispensed by means of a monitored dosage (blister pack) system by staff who have completed medication training, and deemed competent by the manager. The home has a policy and system to ensure residents’ medication is stored, administered and recorded safely. During the site visit the inspector looked at the arrangements in place and noted there are locked facilities in a designated medication room. All medication records were found to be well maintained. Privacy, dignity and respect The manager and staff spoken with confirmed that the importance of respect for people’s dignity and privacy is covered in the first unit of induction training for new staff. On the day of the site visit the inspector spent time with residents in the communal areas and observed the staff at work. Staff were noted at all times to be respectful and kind towards residents, calling them by their preferred names and knocking on doors before entering rooms. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 13 While all residents and relatives spoken with during the site visit were full of praise for the staff and their approach to care, one negative issue raised in the visitors/relatives survey was fed back to the manager who agreed to address it. Residents can use the facility of the home’s portable phone to make and receives calls and/or they can have installations in their own rooms on request. The manager confirmed that all rooms in the new build would benefit from preinstalled telephone points. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 14 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 and 15 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Kynance offers a flexible and varied service where choices and preferences are encouraged and supported. The activities offered aim to suit the needs of the residents. Friends and family are made to feel welcome and can visit at any time. Residents are encouraged and supported to manage their own financial affairs for as long as they wish and are able. Currently where difficulties arise, family members are available to assist. The promotion of choice extends to all aspects of daily living including personalisation of rooms, and meals. Residents’ nutritional needs are satisfied with a varied and balanced diet of good quality food. EVIDENCE: Routines and activities – The manager said that the home promotes residents’ independence and where possible supports them to take part in activities they did before entering the Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 15 home. However, it is fair to say that several residents need supervision with some daily activities. Information in care files identifies residents’ preferences for daily routines, possible problems and how they will be managed. One visitors/relatives survey response indicated that most of the stimulating activities had stopped. This is a reference to a time when one activities co-ordinator organised a range of activities in the home throughout five days of the week. The manager, staff and most of the residents spoken with described the current programme of activities, which includes: • • • Monday and Friday – trips out in the minibus. Tuesday mornings – a visitor organises exercises, quizzes and games. Wednesday – another visitor provides artwork sessions with the residents. The manager said that typically there is a take-up of about eight residents for the minibus trips, which increases during the summer months. In discussions with a group of residents in the lounge and with individuals in the privacy of their rooms it was clear that some enjoyed the activities and others were not interested; some enjoyed the excursions in the minibus while others showed no interest. The home provides a loop system in the main lounge to help those with hearing impairments. The manager said that the home would support residents to attend church or arrange for a minister to visit the home on request. However, arrangements for religious observance had been discussed at residents meetings and had not been met with any interest. During the site visit the inspector noted that interactions between staff and residents was warm and good-humoured. In the afternoon staff had time to sit and chat with a group of residents in the lounge. Visiting arrangements – Details of visiting arrangements can be found in the service user’s guide. Visitors are generally welcome at all reasonable times, i.e., between 10:00 and 21:00. However, arrangements can be made in special circumstances outside the specified times. Residents can receive visitors in their own rooms or any of the communal areas. In addition to the main lounge and dining room there is a conservatory, and a lounge on the first floor, which offers quietness and some privacy if required. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 16 All responses to the visitors/relatives survey indicated they were always made welcome and could visit their relative/friend in private. Personal autonomy and choice – Residents were spoken with as a group in the ground floor lounge and some individually in the privacy of their rooms. Due to some cognitive impairment it was not possible to obtain informed views from everyone. However, the consensus from others was that they were given choices regarding routines in the home, e.g., times of rising, going to bed, activities, meals, personal care etc. The manager confirmed that all residents have either a family member or representative able to support them independently of the home. Residents are encouraged to bring with them pictures, ornaments and personal items for their room. During the tour of the building it was noted that some rooms were well personalised, and reflected the residents’ individual tastes and preferences. The management of residents’ finances is covered later in the report but in a general sense they are encouraged to handle their own financial affairs for as long as they are able. The manager confirmed that some residents were well able to handle their own affairs, while families took that responsibility for others. Meals and mealtimes – The inspector had an opportunity to observe residents and staff at lunchtime. The atmosphere in the dining room was sociable and friendly. Staff were available to assist residents as and when required. Food served looked appetising and was well presented, with a choice of two hot and one cold meal available. All residents spoken with made very complimentary remarks about the lunch and the standard of food in general. Most residents take their meals together in the dining room, although some prefer to eat in their own rooms. Menus are arranged over a four week cycle and show food to be varied and nutritious. The cook maintains good records of what residents are actually served on a daily basis. The inspector noted that drinks and light snacks were offered to residents through the day between meals. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 17 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 and 18 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home treats residents’ complaints seriously and responds appropriately. The home’s policies, procedures and practices ensure that residents are safeguarded from abuse. Procedures for responding to suspicion or evidence of abuse are robust. EVIDENCE: Complaints The home has a policy and procedure for dealing with complaints, details of which can be found in the statement of purpose, and the service users guide given to all new residents or their representatives. Additionally, a copy of the complaints procedure is prominently displayed in the hall near to the visitors’ book. The pre-inspection information provided by the manager indicated that no complaints had been made in the past year. Due to the cognitive impairments of some of the residents it was difficult to gauge their knowledge of how to make a complaint. However, those able to give informed views were very clear that they would go to the manager, the deputy or one of the senior staff with any concerns. They all felt confident that any concerns would be able to be resolved. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 18 The home arranges residents’ meetings every six to eight weeks. A record is kept of any issues raised, so that they can be addressed. The manager said that food and activities tend to be the most popular subjects discussed, although the building development work has recently been high on the agenda. Visiting relatives were very clear about the complaints procedure but so far had not needed to use it. Eight of the fourteen responses to the visitor/relatives survey indicated they new the home’s complaints procedure. This and the arrangements in place to inform people of the procedure shows the standard is met. Adult protection The home has a written procedure for the protection of adults at risk, which follows local authority guidance. The protection of vulnerable adults is covered in the NVQ training for staff, of which 56 are now qualified. In addition, a specific Safeguarding Vulnerable Adults training course is booked for staff during April and May of this year. Staff spoken with were very clear about how to recognise abuse, what to do, and the importance of reporting issues of concern without delay. They confirmed that training was given. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 19 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 and 26 – Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for its stated purpose in providing a safe and comfortable environment for those who live and work there. Decoration, maintenance and refurbishment are ongoing. All areas of the home are kept clean, hygienic and there are no unpleasant odours. EVIDENCE: Environment – Kynance has been a residential care home for older people in East Cowes for many years and while not purpose built has been developed and adapted over the years to be suitable for its stated purpose of providing a safe, manageable and comfortable environment for the people who live there. The home is located in York Avenue, and is only a short distance from the town shops and the chain ferry across to Cowes. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 20 In recent years, various developments in the home have provided en-suite facilities to the bedrooms, increased communal space, wider door openings and a passenger shaft lift to accommodate three people, or one person with a wheelchair. All areas of the building are accessible to residents, including a newly created patio at the rear where residents can sit when the weather is fine. The home is generally comfortable, well furnished and decorated. There was evidence of continued improvements with building work currently in progress to provide additional high quality accommodation and a new assisted bathroom. The home employs a maintenance/handy man who deals with all maintenance issues as and when they occur. When residents’ rooms are vacated, they are redecorated and new carpets laid where required. There is a shower/wet room and assisted bathroom, both with a toilet and wash hand basin on the ground floor. While there are currently bathing facilities on the first floor they will be reconfigured and upgraded in the new build. Residents spoken with during the inspection made very positive comments about the environment. However, it was noted that facilities did not currently fully meet a resident’s needs. These had already been taken up with the manager, who had made an effort to resolve the problem. Cleanliness The inspector toured the building with the proprietor. Two housekeepers employed through the week, with three on a Friday keep the home very clean, hygienic and free from unpleasant odours. A spacious laundry is located in the basement and has large commercial grade machines, enabling soiled articles to be washed at appropriate temperatures. There is a separate sluice facility for effective management of soiled articles due to incontinence. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 21 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 and 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are deployed in sufficient numbers and have the necessary skills and experience to meet the needs of the people who live there. To ensure residents are in safe hands arrangements are made for staff to undertake NVQ training. At the time of the inspection the home had achieved a ratio of 56 of care staff trained at NVQ level 2 or above. The home operates a robust staff recruitment procedure, which ensures service users are protected. The staff training and development programme ensures the residents’ needs are met in line with the aims of the home. EVIDENCE: Staffing levelsThe home employs sixteen care staff, with additional domestic, catering and maintenance staff. Staff rosters showed and the manager confirmed that three care staff are deployed throughout the day, with two waking scare staff overnight. The manager and deputy work additional to those on roster. On the day of the site visit there were twenty-three service users resident in the home with three care staff, the manager and her deputy on duty. These Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 22 staffing levels are considered sufficient for the current needs and numbers of residents in the home. Thirteen of the fourteen responses to the visitors/relatives survey indicated there were always sufficient staff on duty. NVQ training – The manager confirmed and staff training records showed that currently 56 of care staff have achieved the NVQ at levels 2 or above. The home’s training programme continues to ensure that this standard is met. Recruitment Individual staff recruitment files were available for inspection and showed that the home’s recruitment procedure includes an application form, job description, contract of employment, proof of identification, two written references and police and Protection of Vulnerable Adults (POVA) checks on all staff. All new staff are given a copy of the General Social Care Council (GSCC) codes of practice. During the inspection the recruitment records of the four new members of staff recruited since the standard was last assessed were checked and found to be in good order. Staff Training – The home operates an induction programme for new staff, which follows the Common Induction Standards recommended by Skills for Care. All staff have personal development plans. Staff spoken with were very clear that the home provides a very good training package using both in-house and external training providers. Records showed that staff training includes: Manual handling Basic food hygiene Basic first aid Adult protection Fire risk assessment Infection control Dementia awareness The social services care manager spoken with felt that in general terms staff provided a good standard of care, but sometimes found difficulty with those displaying challenging behaviour. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 23 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 and 38 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home where the registered manager has the experience together with the relevant management qualifications to run the home and meet its stated purpose, aims and objectives. There are good quality assurance measures in place to ensure the home continues to meet its aims and objectives. The home has no involvement with service users’ financial affairs other than to provide a facility for safekeeping money or valuables on request. Policies, procedures and practices ensure so far as is reasonably practicable the health, safety and welfare of service users and staff. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 24 EVIDENCE: Management – The registered manager Mrs Corinne Lovejoy has been in post since November 2003. She has sixteen years experience in a service for older people, nine years of which was as a deputy manager. She is fully qualified, having achieved the Registered Managers Award, NVQ at levels 3 and 4 and a Certificate in Management. Staff spoken with during the site visit felt the home was well managed; staff morale was high and communication was good. Quality assurance – The manager showed the inspector a quality assurance audit tool, which covers all aspects of the service, including policies, procedures, maintenance and refurbishment. The company has a development plan for the home, and the evidence of continued improvements to all aspects of the service demonstrates the home’s commitment to quality assurance. The manager gave examples and the inspector saw records of the home’s approach to quality assurance, which includes: • • • • • • • The quality assurance audit tool. Regular residents meetings where issues are recorded and addressed. Yearly care reviews involving the social services care manager, the resident and a relative. Regular in-house care plan reviews. Regular visits throughout the week from the proprietor, who is the Responsible Individual for the Company. Comment cards sent to short term residents at the end of their stay. CSCI comment cards always available in the front hallway to the home. It was noted that while there had been a significant response to the CSCI survey from visitors/relatives, there had been only one response from a resident. In discussions with the manager it was recommended that the home includes written feedback from visitors/relatives as part of the quality assurance and monitoring systems. Residents’ monies – The home provides a facility for safeguarding some residents’ monies and making small incidental purchases. The inspector looked at the system in place by way of dip sampling and found records balanced and receipts were kept. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 25 Health and safety – The home’s pre-inspection information signed by the manager confirmed that policies and procedures were in place to ensure safe working practices in the home. A sample of records was viewed including accident records, fire alarm tests, public liability insurance, and gas and electrical certificates, all of which were in good order. Staff training records showed, and staff confirmed that statutory training is scheduled and updated in manual handling, first aid, fire training, infection control and food hygiene. Kynance DS0000012505.V325803.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 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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 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 3 x 3 x x 3 Kynance DS0000012505.V325803.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 OP33 Good Practice Recommendations To include written feedback from visitors/relatives as part of the quality assurance and monitoring systems. Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Kynance DS0000012505.V325803.R01.S.doc Version 5.2 Page 29 - 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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