Inspection on 04/08/09 for Kynaston Care(80)

This inspection was carried out on 4th August 2009.

CQC 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 CQC judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kynaston Care(80) 01/10/07

Kynaston Care(80) 30/01/07

Kynaston Care(80) 15/12/05

Kynaston Care(80) 29/07/05

Kynaston Care(80) 13/01/05

Kynaston Care(80) 05/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report CARE HOME ADULTS 18-65 Kynaston Care(80) 80 Kynaston Avenue Thornton Heath Croydon Surrey CR7 7BW Lead Inspector James Pitts Key Unannounced Inspection 4th August 2009 11:35 Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kynaston Care(80) Address 80 Kynaston Avenue Thornton Heath Croydon Surrey CR7 7BW 020 8665 4798 F/P 020 8665 4798 farisean@yahoo.co.uk 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) Mrs Efilidah Tambudzayi Smith Manager post vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only – Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 1st October 2007 Date of last inspection Brief Description of the Service: 80 Kynaston Avenue is registered to provide support to three young adults with learning disabilities with a variation granted to allow one person over the age of 65years to live there. The home is owned and managed by Mr and Mrs Smith and is run as a small family type service. Located in a quiet residential area in Thornton Heath, there are accessible transport links within easy reach, including buses and trains. There is a ground floor bedroom and two bedrooms on the first floor with a staff sleep in room situated in a loft extension. Communal areas include a lounge, kitchen / dining area, bathroom / toilet and a good size garden available to the service users. Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The rating for this service is 1 Star which means that the people who use this service experience adequate quality outcomes. This unannounced inspection took place on a Tuesday, starting late morning. Three people who use the service were present and they appeared to be content and interacted without any hesitation with the people who care for them. One person spoke at length about liking the staff and feeling comfortable living here and another made a passing comment saying that they felt ok. A number of standard records were examined, including the care plans for all but one of the people who live here. The newly appointed manager, to be confirmed in post pending registration with the Commission, was also present. Two members of the staff team also made positive comments about working at this service. Questionnaires were sent to the people who use this service prior to the inspection although to date none have been returned. They are very welcome to complete these at a later date if they wish too. What the service does well: What has improved since the last inspection? What they could do better: Effectively there has been deterioration in the service performance. Please refer to the 12 requirements and 3 recommendations that are listed at the end of this report for specific details of the improvements that are required. Please also refer to these requirements in respect of the response Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 6 that the service has provided below. Where evidence was not available during the inspection site visit, or provided by written evidence at the draft report stage, the progress will be evaluated at the next key standards inspection. Standard YA1 Regulation 4&5 Requirement Updating Statement of Purpose and Service Users Guide Making Care Plans accessible for service users who cannot read their care plans. Systems for recording complaints, including any investigation and to response to complaints. Unexplained injuries that have occurred. Response Both documents have been updated and dated August 2009. The current care plans have now been made available in Audio form. We have updated our complaints and compliments policy and put in place ways of recording complaints. August 2009. We have constantly liaised with the Day Centre service and the placing Authority regarding this issue. The specific service user is known for self harming and this is well documented in their Needs Assessment and Risk Assessment. The new arrangement and agreement with the placing authority now is that all the Version 5.2 Page 7 YA6 15 (2) (a) YA22 22 (3) & (8) YA23 13 (4) (C) Kynaston Care(80) DS0000025805.V376298.R01.S.doc YA32 18 (1) (a) NVQ level 2 YA33 18 (1) (a) Staff duty rota YA43 19 (1) (b) Schedule 2 CRB YA35 18 (1) (c) (i) & (ii) Staff training/developme nt plans Incidents whether it happened at the Day Centre or at home we keep a record of it and fax incident forms to the placing authority. We had three staff who where qualified at NVQ level 2 and above. One left the organisation, the other transferred to another home owned by the Registered Provider and one is still with the organisation. The other two staffs are attending classes for their NVQ Level 3 which is due to be completed soon. The staff duty rota has been amended since August 2009. All CRB for new members of staff were obtained before commencing work. The POVA you saw in staff files were old staff members that needed their CRB renewed. Staff training/developm ent plans are already in place and in staffs file. These are already in place and were Version 5.2 Page 8 Kynaston Care(80) DS0000025805.V376298.R01.S.doc YA35 18 (1) (c) (i) Staff training YA36 18 (2) Staff supervision YA39 24 (1) Quality Assurance / Annual Development Plan there on the day of inspection but were never asked for. We are unclear how you came to the conclusion that most of the training is in house. None of the training certificates in the staff files were all by External Accredited Training Providers. We are a member of the Croydon Learning Disability Forum and they arrange all the training through Accredited Training Providers. We do provide in house training to reinforce gained knowledge and skills but have not issued certificates. When the new Acting Manager joined us she updated our Supervision Policy and supervision record so we have new format in place and all our staff supervision record are up to date. The surveys we sent to relatives were received back and the Annual Version 5.2 Page 9 Kynaston Care(80) DS0000025805.V376298.R01.S.doc YA42 23 (2) (c) Legionellosis check Development Plan has been updated accordingly. A test was done on the 11/09/09) and we are awaiting the result. As soon as the result comes out a copy of the certificate will be sent to you as soon as possible. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 10 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 Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 1, 2 & 3 were assessed at this inspection. The people who use this service and other people are told what the home does and how it will do it. The service user guide and statement of purpose do need updating to reflect recent changes to the staffing and management structure of the service. EVIDENCE: The people who use this service, and others, are told what the home does and how it will do it, and the guide for service users is presented in a clear way. However, both the statement of purpose and service user guide now need updating to reflect changes to the staffing and management structure of the service and any additional charges made. The date of the review of these documents must also be included on them. The home has had one person come to live here and the necessary pre – placement and assessment documentation that we looked at were completed. These indicate that this person is appropriately placed at the home at present although the placing authority has yet to confirm this as a permanent Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 12 placement. It is suggested that the service ask the placing authority to clarify this person’s status in respect of ongoing residence so that this person can have their longer term plans and goals identified. Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 6, 7 & 9 were assessed at this inspection. The people who use this service can feel more confident that staff know what they need. The home has a keyworker system which is undergoing further revision in order to further support this work. EVIDENCE: We looked at the care planning and review information for three of the four people who use this service. A keyworker system is in operation at the home. A keyworker is a member of staff who especially makes sure that individual service users are being supported in the right way. Keyworkers have the primary responsibility for keeping care plans and risk assessments up to date and at this inspection it was seen that this continues to occur. The newly appointed manager has begun to introduce regular one to one keywork Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 14 meetings to ensure that ongoing care and support needs are kept under review. The service user’s care plans that were looked at in detail show that the preferences and needs of each person are given the proper consideration. One previous recommendation that was made for improvement was that for two service users who are not able to read their care plans should be presented in a more accessible way. This would allow these people to have a more in depth knowledge of their care plan should they wish to see what it contains. This recommendation has yet to be addressed and will now result in a requirement to do so in this report. The home compiles a risk assessment for each of the people who live here. A risk assessment tells the staff how to make sure that each of the service users is kept safe from anything that might harm them. The staff are still doing this about very particular needs for each of the people who live here. Each of these people has a risk assessment that was updated recently. Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 15 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): This is what people staying in this care home experience: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 12, 13, 15, 16 & 17 were assessed at this inspection. The people who use this service can feel confident that the staff team supports the opportunity for each to develop and maintain their preferred lifestyle as well as personal and family relationships. EVIDENCE: The people who use this service are supported by the staff to be as independent as possible and to make as many choices as they can. All but the newest of these people engages in either organised or independent daily activities. The service is working to secure a regular daily programme of day centre or drop in centre activities for the other person although until this Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 16 occurs they have staff support to engage in leisure pursuits. Apart from this all are engaged in other activities of their choosing each week. Due in part to the ages of most of the people who live here, they each have a very settled routine and chosen lifestyle. The newly appointed manager is currently undertaking a piece of work to look further at the opportunities and variety of activities that are offered to examine if there are new activities that people may wish to engage in. The staff encourage continuing contact with families and friends. All of the people who live here are allowed to use the entire house, except other people’s bedrooms or the office. The menus that we also looked at properly reflect the meals that people have. The menu is a weekly rotation that provides an accurate picture of the meals that are offered and chosen each week. All staff involved with food preparation have been trained in essential health & safety courses i.e. food hygiene practices. Food stocks were looked at and there was a plentiful and varied amount of fresh, refrigerated and frozen food available. Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 18, 19, 20 & 21 were assessed at this inspection. The people who use this service can feel confident that they will get the right support to take care of their physical and healthcare needs. Anyone who needs to take medicine regularly to help them stay well will get the proper support from staff to make sure that this happens. EVIDENCE: Each of the people who live here has a care plan that tells the staff about the way that each person wants to be cared for and supported and about what each person likes or does not like. The care plans do indicate the particular degree and type of support that each person needs to manage their personal care, although as referred to earlier in this report there is a need to present these plans in a more accessible way. Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 18 All of the people who live at the home usually go to see a local GP if they are not feeling well. They can see any local GP but most see the same one. The staff are good at writing down anything that happens if anyone becomes unwell and also write about the outcome of any medical appointments that people attend. If anyone has an illness or something else is wrong with them then the staff do know what this is and how to help them to get the treatment that they need. Most of the people who live here need to take medicine every day and the staff make sure that this happens so that they can stay well. The fact that staff have to control these medicines has been previously agreed with the individual and their placing authority. The staff also make sure that no one can get hold of any medicine that they should not have and so they keep medicines locked away. Medication training for staff has been most recently updated in June of this year. Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 22 & 23 were assessed at this inspection. The people who use this service cannot feel entirely confident that the staff team at the home know what appropriate practise in managing personal finances is in an acceptable way. The service does, however, have clear guidance for staff about the procedures to be followed if other types of complaint or concern are raised. EVIDENCE: The people who live here, and others, are given clear information about how to complain and what happens when they make a complaint. We were informed that no complaints have been made to the service since the previous key standards inspection. However, the service does not currently have a system for recording complaints and one must be established. No complaints have been made to the Commission by people who use the service, or their relatives, since the previous key standards inspection. Concern has been raised by the placing authority in respect of charges that have been levied for the one person who the staff team support with managing their personal finances. It was alleged that charges were made for staff food Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 20 and travel expenses incurred during the normal process of day to day support in the community. The service responded fully to the local authority and provided evidence that this had not in fact occurred. Another concern was raised about injuries sustained by one person who uses the service. The home states that these injuries have occurred at the day service that this person attends and have been reported to the placing authority. Examination of contacts that have been made in recent months show that the service has been in contact with both the day care service and placing authority about these. There is clearly some difference of opinion about the timing of these injuries and where they may have occurred. The service needs to resolve this concern satisfactorily with the placing authority and agree a protocol for examination of unexplained injuries. All but the newest member of the staff team have had updated training in respect of the geographical authority protection of vulnerable adults procedures and this should now occur for the remaining member of staff. Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 24 & 30 were assessed at this inspection. The people who use this service can feel confident that they are living in a well maintained and clean home. EVIDENCE: Each of the people who live at Kynaston has their own bedroom and shared access to a lounge and kitchen / dining room, as well as a small garden at the rear of the house. No one needs to use any specialised equipment or require specific adaptations in order to cater for their physical care needs. A tour of the premises that we carried out shows that the house is kept very clean, is a warm and comfortable environment and is free of any unpleasant odours. Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 32, 33, 34, 35 & 36 were assessed at this inspection. The people who use this service cannot feel confident that there is an effective or safe recruitment procedure or that the staff team are fully qualified, trained or supported to carry out their duties. EVIDENCE: The law says that half of the staff must have a proper qualification to work with adults who need support in a care home. The name of this qualification is NVQ 2. The service stated on the annual quality assurance document that was sent to the Commission that three staff were to this level, however only one member of staff has evidence of this on their personnel file. The registered person must confirm the details of this qualification, and who is qualified, in writing with the Commission. Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 23 There have been two new care and support staff come to work at the home since the previous key standards inspection. Neither of these people had a verified CRB check in place, although a POVA first check was carried out. However, POVA first checks are only permissible in exceptional circumstances and the service cannot prove that this was the case for either of these staff. The service must ensure that CRB checks are carried out and the result is obtained prior to any new members of staff being permitted to commence their duties at the home. This requirement arose before at an inspection three years ago and it is unacceptable for the service has failed in this area again. The first names of staff appear on a rota, however, the rota must state the full name of staff on duty for accuracy and verification purposes. Two staff have signed a waiver to the European working time directive resulting in each working an average of 50 to 58 hours per week and covering almost all of the sleep in duties each night. It was also noted that these staff have also agreed to work for the domiciliary care agency that the registered person also operates. This could result in these staff being asked to work excessively long hours and be at risk of being too tired to properly carry out their duties at this service. The registered person should ensure that the health and well being of these employees is regularly monitored so as to ensure that they remain both mentally and physically fit to perform their duties. Staff training / development plans were still not in evidence although an appraisal system is in place. Staff performance, once assessed, must then lead to appropriate ongoing training and development programmes in order to enhance their skills, as was required at the previous key standards inspection. The type of staff training that is being provided is often in house training. The service must ensure that professional training is provided by an accredited training provider. As a result of the concerns that are referred to earlier in this report the local authority has provided intervention from their care service support team which may be of benefit to the service in meeting this requirement. The home employs only three people, aside from the manager. Staff are supposed to meet with their direct line manager at least 6 times a year by law. The home still cannot show that this is happening although improvements were previously made this appears to have faltered once more. Staff must be supervised at appropriate intervals to support the professional nature of the work that they are required to undertake. The requirement that was previously made about this matter will remain in this report and it must be fully and properly addressed without further delay. Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 37, 39, 40 & 42 were assessed at this inspection. The people who use the service cannot feel confident that they are living in a home that has a properly effective standard of internal management. They are, however generally safe from hazards in the house in which they live. EVIDENCE: Mrs Smith, who is also the registered person, has extensive knowledge and working background of care services of this kind. She is also qualified to NVQ level 4 management qualification to comply with current National Minimum Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 25 Standards and Regulations. However, since the previous key standards inspection there has clearly been deterioration in the day to day management oversight of the service. This is reflected by the number and nature of the requirements in this report and the failure to address the previous two requirements and one recommendation that were made in 2007. A new, currently acting, manager has been appointed recently. Pending the outcome of this person’s application to register with the Commission their appointment may be confirmed at a later date. It is fair to say that during the discussions that were held with this person during the course of this inspection that they demonstrated a sound knowledge of the service type and of improvements that need to be made. As it is intended by the registered person to permanently appoint a manager, as stated above, Mrs Smith will need to be mindful to establish monthly monitoring visits as required under regulation 26 once this appointment is confirmed. The people who use this service and relatives have been recently asked about their views of the home, this must now lead to an update of the annual development plan. Some policy and procedure documentation has been updated recently by the acting manager. It is recommended that the rest be reviewed and updated by the end of this year. The service received a 4 star rating for food hygiene from the environmental services department of the geographical authority in December 2008. The homes fire and other safety certificates were examined at this inspection and all were found to be up to date, except for a legionellosis check which must be carried out. None of the fire extinguishers have verification labels upon them to show when they were most recently checked. Checks of the fire extinguishers must be carried out and the date / confirmation signature are written by the maintenance engineer on a label to be attached to each extinguisher. Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 1 2 3 3 3 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 1 35 1 36 1 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 3 3 2 X 2 2 X 1 x Version 5.2 Page 27 Kynaston Care(80) DS0000025805.V376298.R01.S.doc YES 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 YA1 Regulation 4&5 Requirement The registered person must ensure that the statement of purpose and service user guide is updated. These are to reflect changes to the staffing and management structure of the service and any additional charges made. The date of the review of these documents must also be included on them. Timescale for action 04/11/09 2. YA6 15 (2) (a) The registered person, for 04/11/09 service users who are not able to read their care plans in written form, must ensure that these are presented in a more accessible way. The registered person must 04/09/09 ensure that there is a system for recording complaints, including any investigation and response to complaints. There is clearly some difference 04/11/09 of opinion about the timing of unexplained injuries and where they may have occurred. The registered person must resolve this concern satisfactorily with the placing authority and agree a DS0000025805.V376298.R01.S.doc Version 5.2 Page 28 3. YA22 22 (3) & (8) 4. YA23 13 (4) ( c ) Kynaston Care(80) protocol for examination of unexplained injuries. 5. YA32 18 (1) (a) The registered person must confirm the details of those who are qualified at NVQ level 2 or higher in writing with the Commission. 04/11/09 6. YA33 18 (1) (a) 7. YA34 19 (1) (b) Schedule 2 The registered person must 04/11/09 ensure that the staff duty rota states the full name of staff on duty for accuracy and verification purposes. The registered person must 04/11/09 ensure that CRB checks are carried out and the result is obtained prior to any new members of staff being permitted to commence their duties at the home. This requirement arose before at an inspection three years ago and it is unacceptable for the service has failed in this area again. Staff training / development plans were not in evidence. The registered person must ensure that staff performance, once assessed, must then lead to appropriate ongoing training and development of their skills. (Previous timescales of 30/04/07 and 08/10/07 have not been fully complied with) The type of staff training that is being provided is often in house training. The registered person must ensure that professional training is provided by an accredited training provider. The registered person must ensure that staff are supervised at appropriate intervals to DS0000025805.V376298.R01.S.doc 8. YA35 18 (1) ( c ) (i) & (ii) 04/11/09 9. YA35 18 (1) ( c ) (i) 04/11/09 10. YA36 18 (2) 04/11/09 Kynaston Care(80) Version 5.2 Page 29 support the professional nature of the work that they are required to undertake with the people who use the service. (Previous timescales of 30/04/07 and 08/10/07 have not been fully complied with) 11. YA39 24 (1) The people who use this service and relatives have been recently asked about their views of the home. The registered person must ensure that this leads to an update of the annual development plan. The registered person must ensure that checks of the fire extinguishers are carried out and the date / confirmation signature be written by the maintenance engineer on a label to be attached to each extinguisher. The Commission must be informed in writing once this has been achieved. 04/11/09 12. YA42 23 (4) (a) 04/10/09 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 YA23 Good Practice Recommendations All but the newest member of the staff team have had updated training in respect of the geographical authority protection of vulnerable adults procedures. The registered person should ensure that this occurs for the remaining member of staff. The registered person should ensure that the health and well being of the employees who work in excess of an average of 48 hours per week is regularly monitored so as to ensure that they remain both mentally and physically fit to perform their duties. DS0000025805.V376298.R01.S.doc Version 5.2 Page 30 2. YA33 Kynaston Care(80) 3. YA40 Some policy and procedure documentation has been updated recently by the acting manager. It is recommended that the rest be reviewed and updated by the end of this year. Kynaston Care(80) DS0000025805.V376298.R01.S.doc Version 5.2 Page 31 Care Quality Commission National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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