Care Home: Kexborough House

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What the care home does well There were many comments about this home and with the exception of one or two minor criticisms, all comments were positive. Specific comments have been put under the relevant sections of this report. The home provided an excellent standard of care, which ranged from meeting people`s individual needs, the comfort and cleanliness of the environment, quality of meals and the friendliness of well trained staff. The owner/managers were committed fully to maintaining the high standards that they had set for themselves. General comments received about the home were, "Maintains a holistic approach to clients` needs and wishes, thus maximising quality of life". "The care home try to accommodate all the residents needs including taking them for medical check ups, and to a local hostelry for Christmas lunch" "A well run home where mum feels safe, secure and happy" "The care home treats the residents as family and provides an excellent service and accommodation. Have no reservations about (person`s name) being in their care." "Clean. Staff friendly""Exemplary service to be followed by other care homes" "Most of my receptionists want a place in Kexborough House when they are older!" What has improved since the last inspection? The two previous requirements were met. Before the inspection, the CSCI received information of the manager`s plans for improvement. At the time of the inspection, work had already been carried out and his plans for improvement had been met. This demonstrated a proactive approach. What the care home could do better: Several recommendations were made during the site visit. requirements but demonstrate good practice. People were asked how the home could improve. included, These are notComments received"The care home at Kexborough House is always in good order", "Continue the same high levels of client care." "Little margin for improvement since already offering excellent service" and "It is difficult to see how the care home can improve on the service it provides." CARE HOMES FOR OLDER PEOPLE Kexborough House 113 Churchfield Lane Kexborough Barnsley South Yorkshire S75 5DN Lead Inspector Christine Rolt Key Unannounced Inspection 4th March 2008 09:40a 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 Kexborough House DS0000018260.V359952.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. Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kexborough House Address 113 Churchfield Lane Kexborough Barnsley South Yorkshire S75 5DN 01226 385046 F/P 01226 385046 none None MJM (Furnishings) Limited 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) Mr Michael Matthews Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd March 2007 Brief Description of the Service: Kexborough House is a Christian home. It is a large brick built residence in the village of Kexborough. The home provides personal care and accommodation for twenty-two older persons. Accommodation is on two floors served with a passenger lift and there is a single storey purpose built extension. All bedrooms have en-suite lavatories. The home operates a no smoking policy. Kexborough House stands in its own grounds and ample care parking is provided at the front of the property. There are large landscaped gardens to the rear of the property with accessible patio areas. Within a short walk from the home there is a full range of amenities including the post office, health centre, shops, pharmacy, community centre, country pubs, churches and local village club. The home is a few minutes drive from the M1 motorway, junction 38. Mr. and Mrs Matthews have full involvement in the running of the home. Mr Michael Matthews is the registered person and manager and Mrs. Marita Matthews is the assistant manager. The Service User Guide and most recent inspection report were available in the visitors’ lounge. The weekly fees were dependent on the size of the bedroom and ranged from £400 to £480. Hairdressing, chiropody, personal toiletries, and personal newspapers (extra to the ones supplied by the home) were not included in the weekly fee and were charged separately. The manager supplied this information during the site visit on 4th March 2008. Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means that the people who use this service experience excellent quality outcomes. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 9:40 am to 5:40 pm. The manager completed an Annual Quality Assurance Assessment before the site visit. This document gave the manager the opportunity to say what the home did well, what had improved and what they were working on to improve. Various aspects of the service were then checked during the site visit. Care practices were observed, a sample of records was examined, a partial inspection of the building was carried out and service provision was discussed with Mr and Mrs Matthews. The majority of people living at the home were seen throughout the day, several were chatted to and two were asked for their opinions of various aspects of the home and the care received. Relatives who were visiting one of these two people were also asked for their opinions. The care provided for three people was checked against their records to determine if their individual needs were being met. A member of staff was interviewed. Questionnaires were sent to seven people living in the home, seven relatives and five health and social care professionals. Completed questionnaires were received from six people living in the home, six relatives and two health professionals. Information and comments are included in this report. The inspector wishes to thank people living at the home, relatives, health professionals, the staff, and Mr and Mrs Matthews for their assistance and cooperation. What the service does well: There were many comments about this home and with the exception of one or two minor criticisms, all comments were positive. Specific comments have been put under the relevant sections of this report. The home provided an excellent standard of care, which ranged from meeting people’s individual needs, the comfort and cleanliness of the environment, quality of meals and the friendliness of well trained staff. The owner/managers were committed fully to maintaining the high standards that they had set for themselves. General comments received about the home were, Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 6 “Maintains a holistic approach to clients’ needs and wishes, thus maximising quality of life”. “The care home try to accommodate all the residents needs including taking them for medical check ups, and to a local hostelry for Christmas lunch” “A well run home where mum feels safe, secure and happy” “The care home treats the residents as family and provides an excellent service and accommodation. Have no reservations about (person’s name) being in their care.” “Clean. Staff friendly” “Exemplary service to be followed by other care homes” “Most of my receptionists want a place in Kexborough House when they are older!” What has improved since the last inspection? What they could do better: Several recommendations were made during the site visit. requirements but demonstrate good practice. People were asked how the home could improve. included, These are not Comments received “The care home at Kexborough House is always in good order”, “Continue the same high levels of client care.” “Little margin for improvement since already offering excellent service” and “It is difficult to see how the care home can improve on the service it provides.” Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 7 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. Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 8 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 Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 9 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): 1, 3 and 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People had the information they needed to make an informed choice. Assessments were carried out to ensure that the home could meet people’s needs. This home does not provide intermediate care. EVIDENCE: People considered that they had received sufficient information to make an informed choice about the home and that the home met their needs. The service user guide and latest inspection report were available in the visitors’ lounge. Information in the service user guide was updated regularly. The files for three people were checked and these showed that detailed assessments had been carried out to ensure that the home could meet each person’s individual needs. Kexborough House DS0000018260.V359952.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 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care and health needs were met fully with person centred planning. were treated with respect. EVIDENCE: The information received showed that people considered that their needs or their relative’s needs were always met. They said that they always received the care and support they needed and staff listened to them. The files for three people were checked. The files were well organised and information was easy to find. The care plans provided specific information of people’s physical, health, emotional and social needs and daily records showed how these needs had been met. People’s needs were closely monitored and there was evidence of changes being made to care plans to accommodate Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 11 People people’s changing needs. and weight charts. Comments were, Files contained risk assessments, monitoring charts “After leaving my home after 70 years it was a big step and upheaval to go into care – having arrived at this home I feel like I am staying in a wonderful hotel on holiday – I wish I had done it years earlier – my health has improved so much” “They are supportive and encourage without being too forceful” and “The staff are caring and think a lot about the residents.” People said that they always received the medical support they needed. Relatives said that they were always kept informed of any incidents that affected people’s wellbeing. One comment was, “Despite the fact that my husband and myself work abroad for approximately three weeks out of every month, they stay in touch with us if it is necessary to do so by means of mobile phone”. Information of visits by or communication with health care professionals e.g. GPs, district nurses was recorded. A person living in the home commented, “Manager takes me in his own vehicle for doctors visits to check ups.” The manager verified this and said that if the person was capable of visiting the surgery then he always took them as this was normality and they were more likely to see their own GP. Health professionals considered that people’s health needs were always met. They thought that staff always sought advice and acted on the information given. Their comments were, “Very caring and involved management and care teams” and “Excellent communication and working relationship with the medical and allied health professionals”. On the day of this site visit, a person living in the home had developed a health problem that required an ambulance to Accident and Emergency. The assistant manager provided support and stayed with the person until the person was admitted onto the ward. The manager said that either he or the assistant manager provided support for any emergency or routine hospital visit and considered that this was their responsibility. The only time that they would not do this was if the person’s relatives stated that they wished to do Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 12 this themselves. At the end of this inspection, both Mr and Mrs Matthews intended to visit the person in hospital before they went home. Accidents forms were completed and placed on people’s files. The manager said that if there were no apparent injuries following an accident, the person would be monitored and notes added to the daily records. The use of 72-hour monitoring sheets was discussed and recommended as a sign of good practice. All senior care staff had undertaken accredited medication training to intermediate level. Medication was stored securely. Medication was delivered weekly therefore any issues were dealt with quickly. The manager said that he carried out audits of medication. The medication for three people was checked. There were no gaps in the Medication Administration Record (MAR) sheets. One person who had recently been admitted to the home did not have their medication in the monitored dosage system (MDS), therefore details of their medication were handwritten. A fresh supply of medication had commenced midweek but the total had not been altered to take account of this. However, this would have been noticed at the end of the week when the medication was carried forward onto a new MAR sheet. This was brought to the attention of the manager who was also advised to obtain a second signature to witness handwritten entries. This is good practice. Medication that needed to be kept cool was kept in a separate box in the domestic refrigerator. At the time of this inspection the home did not have any controlled drugs. One person said that he had noticed a big improvement in his mother since she had moved into the home. His mother verified this and said “Yes, and I’ve put on half a stone in weight”. People living in the home were well groomed and there was attention to detail with personal accessories. Staff were observed to treat people with respect and kindness and to knock on bedroom doors and wait for an answer. People considered that they were treated with respect. A comment was, “Staff are wonderful – well trained, polite, caring and thoughtful” The home used a pager system instead of the normal buzzer system. All care staff including the manager carried pagers. This maintained a calm environment and meant that people living in the home were not constantly disturbed by the noise from buzzers. When assistance was required the system activated all of the pagers and identified the room where assistance was needed. When staff responded, the call was cancelled and the pager was reset. This system also promoted privacy as only the person requesting assistance and the staff were aware that a call had been made. Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People received nutritious and appetising meals in pleasing surroundings. The lifestyle did not always match people’s expectations and preferences. People were empowered to exercise choice, and contact with family and friends was promoted. EVIDENCE: Comments about the frequency of activities available were mixed. Some considered that activities were always or usually available and comments received were, “I have my hair done regularly, nails and toes manicured and pedicured”, “Confirmation/church visits, theme meal nights, like Harvest and Halloween”. “I had a game of dominoes this morning.” Others felt that activities were only available sometimes. Kexborough House DS0000018260.V359952.R01.S.doc Comments were, Version 5.2 Page 14 “Would like one afternoon per week of activities, e.g. dominoes, bingo, music” “Maybe a few more activities” “Perhaps an ‘Activity’ table would be useful for jigsaws, writing, card/board games or just sitting round and talking” “Some experience trained person giving gentle exercise” The manager said that activities usually took place during the morning when people were alert. He said that a member of staff did gentle exercise with those who wanted to join in and another member of staff did craft sessions. There were crossword sessions, quizzes, sing-alongs and various games including Play Your Cards Right, dominoes and table games. He said that he would consider setting up a table for activities during the afternoon but added that people tended to like to have a nap during the afternoon and generally couldn’t be persuaded to join in activities. Church services and communion services were held in the home. Some people attended church services and prayer meetings in the community. There was also a coffee morning at the local church each month. Trips were organised for shopping or to places of interest. Individual activities in the community were arranged. The manager also added that when people were taken for appointments to hospital or the GP, the outing was usually extended to include a visit to a place of particular interest to the person or a visit into town for a cup of coffee. Relatives said that they were always made welcome and refreshments were provided. They were always helped to keep in touch. A relative explained the system used for helping to keep in touch by telephone. Some people had their own telephones in their bedrooms. The public telephone was in the visitors’ lounge, which provided privacy when making, or receiving calls. A comment was, “Everyone is welcomed and they make it feel like a home”. People considered that they were supported to make their own choices. Information in people’s files showed that people’s preferences were listed and staff were observed offering choices. People said that the food was always good. One person considered it “Fantastic” and also volunteered the information that fresh fruit was available every day. Other comments were, Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 15 “Food very good”, “Food is wonderful, freshly prepared tastes home made! clean tables, food is hot” and “The food is very good according to my mother”. Choices were available at all meals and special diets were catered for. The manager said that the cook, who was available all day, spoke to each person individually for his or her choices. One person related an incident that had happened whilst she was having porridge for breakfast. Whilst chatting to a person on the same table, she mentioned that when she lived in her own home she liked to slice a banana into her porridge. She said that the cook must have overheard her and she was pleasantly surprised when the cook came out, sliced a banana into her porridge and said that she could have whatever she wanted. The main meal of the day was served late afternoon as it was considered that people tended to eat better at this time. The manager and staff gave discreet assistance to people who needed help at meal times. The dining room was pleasant. Different coloured tablecloths were used for each meal. Each table contained condiments, teapots, sugar, milk and serviettes. The assistant manager said that they only used well known branded foodstuffs in the home e.g. Heinz beans. Presented at nice Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 16 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home and their visitors knew how to complain and were confident that any complaint would be dealt with effectively. People were protected from abuse. EVIDENCE: The home had a complaints procedure. This needed amendment to include recent changes to the CSCI contact details. People said that they knew how to complain and considered that complaints would always be dealt with appropriately. A comment received was, “Haven’t had any cause to complain in almost three years” The complaints book was checked. There was only one complaint and this had been dealt with to the satisfaction of the complainant. There were no allegations of abuse. The manager said that all staff had received adult protection training and he had recently attended the familiarisation session on the new South Yorkshire safeguarding procedures. Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was pleasant, hygienic, well maintained and safe. EVIDENCE: The home created a good first impression for any new visitor. It was pleasant and clean with a calming atmosphere and there were no offensive odours. All rooms were warm, well decorated and well lit. Information received before the inspection listed the plans for future improvements to the environment. These included replacing the lounge window, replacing a door, decorating both lounges and re-carpeting one lounge and a hallway. All these improvements had been carried out. People living in the home had been involved in the redecoration of the lounges and asked to choose the wallpaper and the colours. Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 18 Bedrooms were clean and well decorated with matching furnishings and bedding. They looked comfortable and were personalised. It was recommended that shelves be provided for toiletries. Bedrooms had en-suite lavatories. Bathroom and toilets were clean. A laundry trolley had been left in one bathroom, there was a disinfectant spray bottle on display and towels were stored on a window ledge. The assistant manager was asked to find alternative storage for the laundry trolley and to consider providing a wall cupboard for storage of towels and other items. Aids and adaptations were in place. The majority of the comments received about the home were positive. People considered that the home was always fresh and clean. Comments were, “Lovely home” and “The cleanliness and smell of freshness in the home is fabulous, the cleaning staff should be proud, the standards are very high.” Mrs. Matthews praised the domestic staff for the high level of cleanliness. A comment from a relative was, “Possibly the exterior of the house needs some attention i.e. fence falling down outside mother’s room, broken panes of glass in outbuildings, but if the choice on how to spend available money, then the care and well being of the residents has to be the priority.” This was discussed with the manager. He said that the panes of glass in the outbuilding had been replaced with toughened glass but had still been vandalised by local youths. He was now looking at a more permanent solution. The fencing belonged to a neighbouring property. The manager said that he had been in contact with the owners and asked them to repair the fencing. The assistant manager said that as part of their quality assurance procedure, the system for dealing with laundry had changed and they were currently monitoring this to ensure that there had been an improvement. Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were protected by the home’s recruitment procedures and staff were trained and competent to do their jobs. The numbers of staff on duty met people’s needs. EVIDENCE: At the time of this site visit there were sufficient care staff on duty. This home does not use agency staff. Ancillary staff were seen throughout the day. People considered that care staff always had the skills and experience to do their jobs and were always or usually available. All new employees undertook induction training that met the Skills for Care criteria. Copies of the training manual were seen. In the information supplied before the inspection, 93 of care staff had been trained to NVQ Level 2 or above in care. The member of staff who was interviewed verified that she had received training to NVQ Level 3 in care. She said that skills training was also available. The most recent training was about diabetes and the majority of staff were undertaking this training. The manager confirmed this and there was also information in staff files. Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 20 The assistant manager said that she observed work practice to ensure that staff followed the correct procedures when helping people. Comments about the staff were, “Staff always friendly”, “I haven’t had any problems or difficulties with any of the staff” and “Nothing is ever too much trouble, it is clear that they care and enjoy it.” The recruitment files for two new members of staff were checked. They contained all the relevant checks and information to verify that people were protected. Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was run and managed in the best interests of people living at the home. Their health, safety and welfare were promoted and their financial interests were safeguarded. EVIDENCE: The registered manager had a degree in business studies and NVQ Level 4 in care. The assistant manager had undertaken the Registered Managers Award. Both were trained assessors and had attained A1 and A2 in Assessing. Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 22 Comment received were, “Excellent service, manager very capable and prompt at requesting intervention if need be”, “The quality of life is good. It gives a feeling of a proper home and not an institution. It is not too big” and “Michael and Marita Matthews are very friendly, gregarious, social people who can talk freely to anyone and at any level. They control their staff well, the house is very well kept inside and very clean. They also make the most of any special day in the calendar, even to the point of having a Halloween party. Very impressive. They do try to make life as interesting as possible for their residents.” The home had a good quality assurance system that included audits of systems within the home, environmental checks and questionnaires. Questionnaires were sent out once a year. They were detailed and covered all aspects of care and services within the home. Information was collated and there were records of the changes made to improve the service. Money held on behalf of people who lived at the home was stored safely. Records were kept and a sample of these was checked against the money and these tallied. Receipts were available for purchases made on behalf of people living at the home. The manager was advised to number the receipts and provide a column in the records to enable easy reference. Mandatory health and safety training (i.e. moving and handling, infection control, basic food hygiene, emergency first aid and fire awareness) was ongoing. Since the last inspection, staff had received training in moving and handling, fire awareness, adult protection and first aid. The manager said that new employees had not undertaken training in basic food hygiene and the assistant manager said that she would look into the availability of this training. A sample of certificates was checked and these verified that systems and equipment within the home had been serviced and maintained within the required timescales. Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X X X X 3 Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 Refer to Standard OP8 OP9 OP16 OP19 OP19 OP19 OP35 Good Practice Recommendations The implementation of 72 hour monitoring sheets will highlight to staff that a person needs to be closely monitored following an accident or fall. The countersigning of handwritten entries on medication administration records is strongly recommended to ensure that information has been copied correctly. The complaints procedure should be updated to include the recent changes to the Commission for Social Care Inspection’s contact details Shelving near to washbasins will ensure that people have sufficient storage for toiletries. Storage for bath towels and spray bottles will ensure that items are not on display and the area will be tidier. It is recommended that alternative storage space be found for the laundry trolley. The numbering of receipts and the provision of a receipts column in people’s finance records (personal allowances) would ensure that there was easy reference to financial information for auditing purposes. Ensure that new employees who deal with people’s meals have basic food hygiene training. 8 OP38 Kexborough House DS0000018260.V359952.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Kexborough House DS0000018260.V359952.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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