Care Home: Kibworth Court Residential Home

Similar services:

• Byars Care Home
• St Marys Nursing Home
• Bramble Lodge
• Parkmanor Residential Home
• Thornham Grove
• Hunter`s Lodge
• London Road Neurological and Specialist Care Unit
• Carlton Care Home

What the care home does well What has improved since the last inspection? What the care home could do better: This was a positive site visit and inspection of Kibworth Court. There was good evidence to demonstrate that people living at the Home are informed on important issues that affect them and they have an opportunity to express concerns or make comments about the care they receive. Staff showed awareness in ensuring people are safe and open to receive comments or concerns from the people living at the Home and their relatives. The care plans could be improved by making them more `person centred`, meaning from the point of view of the individual person that promotes and maintains their independence, abilities, routines and important factors in relation to any disability. Kibworth Court should ensure that the policies and procedures are kept under review and reflect changes in legislation and best practice. CARE HOMES FOR OLDER PEOPLE Kibworth Court Residential Home Smeeton Road Kibworth Beauchamp Leicestershire LE8 0LG Lead Inspector Ms Rajshree Mistry Unannounced Inspection 27th May 2008 09:30 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 Kibworth Court Residential Home DS0000001739.V365283.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. Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kibworth Court Residential Home Address Smeeton Road Kibworth Beauchamp Leicestershire LE8 0LG 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) 0116 2792828 0116 2793188 kibworthcourt@newbloom.co.uk Firstsmile Limited Linda Robinson Care Home 40 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (4), Old age, not falling within any other category (40), Physical disability over 65 years of age (4) Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories 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:Old Age, not falling within any other category - Code OP Dementia - Code DE(E) - Maximum number of places - 10 Mental Disorder - Code MD(E) - Maximum number of places - 4 Physical Disability - Code PD(E) - Maximum number of places - 4 The maximum number of service users who can be accommodated is : 40 To be able to admit the person of category DE named in the variation number V11968 30th January 2007 2. 3. Date of last inspection Brief Description of the Service: Kibworth Court is a purpose built care home for forty older people. It is set in the village of Kibworth Beauchamp, close to a variety of amenities. The premises consist of two floors, and people living at the Home have access to both floors with the use of the passenger lift or stairs. There are a variety of aids and adaptations in the Home, based on individual residents assessed care needs. There are thirty-eight single bedrooms and one double bedroom, all with en suite facilities. There are additional toilet and bathroom facilities on both floors. The home has a garden to the rear of the premises. The Deputy Manager provided the following fees during the site visit on 27th May 2008, which ranges between £450 and £500 per week. There are additional charges for services such as Chiropody, hairdressing services newspapers, clothing and personal toiletries. The latest CSCI Inspection Report is available at the home. Kibworth Court Residential Home DS0000001739.V365283.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 2 star. This means the people who use this service experience good quality outcomes. ‘We’ as it appears throughout the Inspection Report refers to ‘The Commission for Social Care Inspection.’ The inspection process consisted of pre-planning the inspection, which included reviewing the Annual Quality Assurance Assessment (AQAA), which is selfassessment tool completed by a representative of the service, reviewing previous Inspection; the Annual Service Review and other information we have received. We sent surveys to thirty-five people who use the service of which one was returned. Thirty-five surveys were sent to families/relatives of the people using the service, of which none were returned, and four health care professional surveys were sent out of which one was returned. Twenty surveys were sent to the staff working at Kibworth Court of which one was returned. Comments received have been included in this report. The unannounced site visit commenced on the 27th May 2008, and took place between the hours of 09:30 and 17:15 hours. The focus of the inspection is based upon the outcomes for people who use the service. The method of inspection was ‘case tracking’. This involved identifying people with varying levels of care needs and looking at how these are being met by the staff at Kibworth Court. Four people accessing services were selected, records were viewed, and observations made about the day-to-day running of the Home. Discussions were held with three people living at the Home, along with some visiting relatives and friends of the people living at the home. Discussions were held with three members of the care staff, the chef the Deputy Manager and the Responsible Individual. Discussion was also held with the visiting District Nurse. What the service does well: People living at Kibworth Court are involved in the admission process and assessment of their care needs. Care plans are developed using the information from the assessment of needs and preferences of daily living that promotes and maintains their independence. People living at the Home are aware of their rights, and know how to complain. People we spoke with said that if they felt unsafe or frightened they would Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 6 speak with a member of staff, family / friend or speak with an Advocacy whose contact details are displayed in the reception area. People living at Kibworth Court continue to receive visitors without restrictions and are able to live the life of their choice; having the opportunity to fulfil their social, leisure and religious needs, with the care and support provided by the staff when required. People living at the Home enjoy a variety of new and traditional meals. Kibworth Court hold regular meetings for people living at the Home, that provides them with opportunities to make decisions and influence the care they receive Kibworth Court has welcoming and relaxed atmosphere. The Home is well maintained and decorated to a good standard with complimentary décor and furnishings. All bedrooms have en-suite facilities, are bright, light and personalised with personal items such as photographs and pictures that create a homely feel. Staff appear professional in their distinct uniforms and wear name badges to help people identify staff. Staff showed a lot of attention, care and compassion towards the people living at the home and their visitors. Comments received in the surveys from people living at the Home, health care professionals and staff working at the Home: “We look after the residents well and ensure their needs are met” “Issues have been addressed appropriately by the care home manager. This has included further training in palliative care, catheter care and pressure area care. These areas have all improved” “ . . . . always contact me if they have any queries or concerns” “ . . . . the care over the past few months has improved. There have been incidents in the past of poor pressure area care and patient’s needs not being fully addressed, however this has not happened in the last 6 months. Recruitment of new staff & training have contributed to this” “There have been improvements. The staff have responded well to the services I provide as community matron and we liaise well with each other”. What has improved since the last inspection? The requirement made at the last inspection has been addressed. The information received from Kibworth Court before the site visit, stated improvements have been to and this was confirmed during the site visit by Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 7 looking at the records, observations and discussions. The improvements include: • Environmental improvements with the development of the new courtyard; new carpets in the communal lounge and dining room and replacing the carpets in the en-suite rooms with non-slip flooring. • The appointment of a Deputy Manager, Activity Co-ordinator and a Chef. • Staff have rotas in advance and have specific duties and responsibilities that ensures the well being of the people living at the Home. • Staff have access to regular training and updates; training provided by the District Nurse and liaise closely with specialist nurses that ensures the needs of the people living at the Home are met. • The wellbeing of the people living at the Home is monitored and communicated with staff and health care professionals, which ensures people have the right care and health support when required. 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. Kibworth Court Residential Home DS0000001739.V365283.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 Kibworth Court Residential Home DS0000001739.V365283.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, 2 and 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving into the Home have access to information about the services provided; have an opportunity to visit the home and are involved in the assessment of their needs to ensure that the Home is best suited to them. EVIDENCE: People considering using the services of Kibworth Court are provided with information in the form of the Statement of Purpose and Service User Guide, which outlines the services provided by the Home. This information is set out in the reception area for people to read, contains details how to make a complaint and contact details of Advocacy Agency. The Service User Guide is currently being updated by the Registered Manager as stated in the information provided by the Home before the site visit. Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 10 Two people living at the Home spoken with said their family visited the home, got information and looked around the home to see if it was suitable. One person said they came to look at the home and having come to a particular bedroom, saw personal items such as Wedge wood plates and family photographs. The visiting relative said “after visiting the Home and thought it was the right place for mother”. We looked at the records of four people who were case tracked living at the Home, of which two were funded by Social Services. The records showed a thorough assessment of persons care needs were carried out before they moved to the Home, looking at all aspects of personal care and daily living needs. The files for two people living at the Home contained a copy of the assessment of needs carried out by the Social Worker. The information gathered enabled the Registered Manager to decide whether the needs could be met by the home. Additional information was gathered from the family of the people looking to move to the home such as family, interests and hobbies and employment. People we spoke with said they were offered a 4-week trial period to see if this place was suitable for them and thereafter their stay was confirmed with a contract detailing the terms and conditions of stay. A copy of the contract detailing the terms and conditions of occupancy is held within the persons records at the Home. Two people whose placement was funded by Social Services also had an Individual Placement Agreement, prepared by the Social Worker, in addition to the Home’s contract. Comments received from the people living at the home and their visiting relatives, indicated that they were involved in the assessment of their needs and the move to the home. We looked at the monthly visit records carried out by the Responsible Individual, which showed assessments records and contracts were checked for people living at the home, indicating that there is an internal auditing system in place. Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 11 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. People residing at Kibworth Court have their individual personal and health care needs met safely by trained staff and health care professionals. EVIDENCE: We looked at the care plans of four people living at Kibworth Court, all set out the personal and health care needs of the individual and guidance for staff to follow that enables the person to have their independence maintained and promoted. Some care plans were personalised, which means it is written from the point of view of the person who requires the support and care. For example: “enjoys his eggs and bacon for breakfast”, this tells the staff the preferred breakfast and “ . . . her right eyesight is poor so she wears glasses, please ensure she has her glasses with her”, this shows the person is encouraged to be as independent as far as possible. Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 12 The information received from the Home before the site visit stated that information about the individual’s personal care and support needs are gathered in the initial 4-weeks trail stay. The care plans were developed with the involvement of the person living at the Home and where possible, their family. Records showed all care plans were reviewed on a regular basis to ensure their privacy and dignity is maintained. The comments received in relation to the improvements made related to providing staff with training in continence care and palliative care, to care for people that may be very poorly or terminally ill. The care plans that we read showed the safety measures that were put in place. These were identified in the risk assessment carried out such as making sure there are no obstructions in the bedroom of a person who is unable to see clearly and making sure staff were protective gloves and aprons when assisting a person to prevent cross-infection. The care plans are written in a sensitive manner that respected the dignity and wishes of the people living at the Home. We read other information in the files of people we were case tracking, which showed people were accessing a range of health care professionals ranging from the General Practitioner, District Nurse, Optician and the Chiropodist. Records are maintained of the visits in the ‘Health / Professionals Visit’ log and support the daily records, which detail the wellbeing of the people living at the Home. We spoke with the District Nurse who said they felt the Home had made improvements, working well with the staff at the Home to ensure people’s health care needs are met; providing hand wash gels and paper towels helps reduce the risk of cross infection. The District Nurse said the staff communicate concerns promptly and seek advice promptly. The staff at the Home benefit from the training provided by the District Nurse Team on catheter care; wound care and recognising infection; palliative care, ‘End of Life’ care for people who are terminally ill and expressed a wish to remain in the home. Comments received from the District Nurse survey “The intention is good, however it is not always possible. Individuals wishes are always listened to and addressed where ever possible”. We spoke with three staff on duty all demonstrated a good awareness of the individual needs, level of support they require and the preferences of the people living at the Home. This showed the independence and the wellbeing of people living at the Home was promoted and they were making decisions. This further supported by the comprehensive daily records made by the staff about the people’s physical and emotional wellbeing. People living at the Home and their visiting relatives all comments that they were treated well and staff were always polite. Medication is stored safely and staff receive medication training, which is regularly updated. The medication records of three people living at the home Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 13 were viewed and found to be in good order. The management and system for ordering, receiving and returning medication is good and auditable. People living at the Home said they always receive their daily medication on time. We looked at the monthly visit records carried out by the Responsible Individual and showed a random sample of care files were checked to ensure care plans were in place and comments from people living at the home indicated that they were satisfied with the care and support provided. This shows internal audits are regularly carried out. Comments received directly from the people living at the Home, health care professionals and staff included: Had my hair done today, showered this morning, . . . great to know you can shower when you want and not have to book in advance” “Praise the night staff . . . . are wonderful, polite and caring” “Had the optician visit last week and I’m waiting from my new glasses” “We look after the residents well and ensure their needs are met” “ . . . . always contact me if they have any queries or concerns” “ . . . . the care over the past few months has improved. There have been incidents in the past of poor pressure area care and patient’s needs not being fully addressed, however this has not happened in the last 6 months. Recruitment of new staff & training have contributed to this” Kibworth Court Residential Home DS0000001739.V365283.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. People living at Kibworth Court experience and enjoy a lifestyle that suits them; having visitors; participate in social events at the Home or in the community and have a healthy choice of meals. EVIDENCE: The information received from the Home before the site visit stated that an Activity Co-ordinator had been appointed. On the day of the visit to Kibworth Court, some people living at the Home were enjoying singing along to ‘Frank Sinatra’ songs in the lounge to the side of the home; a few ladies had their hair done by the visiting hairdresser in the room close to the lounge. The Activity Co-ordinator was seen assisting people that wanted to listen to music into the lounge from the dining room. We spoke with two people living at the home who preferred to remain in their bedrooms. One person said they attend the service held at the Home every month and enjoyed listening to music in their bedroom. After some discussion about the person’s interests, it transpired the they would enjoy listening to the Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 15 ‘talking books’, which means stories that are in CD or tape format for people with poor or no sight. Upon discussion with the Deputy Manager, several talking books were made available with the tape player to the person, who later said they have enjoyed having something different to listen to. We read the care plans for the people that were case tracked, where known, people’s social interests and hobbies were recorded such as music, reading, listening to music and making dolls. It was evident throughout the day the people living at the Home were making decisions about their day from what they wish to eat to how they wish to spend the day. People who live at the Home have the opportunity to develop and maintain their personal and family relationships; visitors are welcome at any time and are made to feel they are visiting their relatives’ own home. Throughout the day, visitors were seen popping into the home to meet with their relatives and some were seen going out with their visiting relatives. Information about the social events and activities are displayed on the notice board at the entrance to the Home. Some people were aware of the planned ‘BBQ evening’ on Thursday, to which relatives of the people living at the home are invited to as well. The information received from the Home before the site visit indicated that the kitchen was due to be refurbished. This was further confirmed when we spoke with the new Chef and his involvement in the design and layout of the kitchen. We spoke with the new Chef about the development of the menus, choice of meals and having balanced and nutritional meals offered. The Chef told us that he ensures any special dietary needs are known; provides freshly made meals using fresh vegetables instead of frozen products. We were told that new meals have been introduced such as spaghetti bolognaise using pasta twirls instead of spaghetti, which people would find it difficult to eat. This showed there was consideration made in providing wholesome and nutritional meals, which can be enjoyed by people in a dignified manner. Care staff were seen to be sensitive to the needs of the people living at the Home who find it difficult to eat, gave assistance with their meals, and remained unhurried. Meals were served at the dining tables individually, appeared to be balance and appealing. People we spoke with said they always have a choice of meals with fresh vegetables and fruit. Comments received from people living at the home were generally positive and included: “the meals are lovely and I would say so if it wasn’t” and “food is lovely, it has improved since . . . been here”. A person with poor eyesight, prefers to eat their meal in the bedroom, said the “staff say what’s on the dinner plate using the clock face and place the knife and fork correctly so that I can eat my meal myself”. This showed staff promoted individual’s independence. Kibworth Court Residential Home DS0000001739.V365283.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the Kibworth Court are confident in raising concerns with staff and are supported by staff that are confident in their role to report concerns regarding the welfare of individuals. EVIDENCE: Kibworth Court has a complaints procedure, which is displayed within the Home, is available in larger print and would look at the possibility of producing it in other languages if required. Alongside the complaints procedure is information about Advocacy services, which includes the contact details, should people living at the Home, wish for an independent person to act on their behalf. We looked at the Complaint Book and saw that the Home had received a few concerns, directly from the people living at the home or their relatives. All were resolved to the satisfaction of the person making the complaint. We received 2 complaints/concerns since the last Key Inspection of Kibworth Court. Both were referred to the Home to investigate and conclude using the Home’s Complaints Procedure. We asked three people living at the Home if they received information about making a complaint. All said they received the information at the time of Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 17 moving to the Home. Two people said they know how to complain and the third preferred to express concerns intitially with their family, who would approach the Registered Manager. We spoke with a visiting relative of a person living at the Home, who was confident that any concerns raised would and had been addressed quickly. Comments received directly from the people living at the Home: “I wouldn’t complain, I would just tell the girls at the time” We spoke with three members of staff to ascertain their knowledge and understanding of safeguarding issues, which means promoting the well being of people using the service from abuse. All were aware of the policies and procedures and that issues of concerns should be reported to the person in charge and were confident to report poor or bad care practices using the ‘Whistle-Blowing’ policy. The senior staff were aware that the Manager’s would inform the Local Authority and the Commission for Social Care Inspection. Staff recruitment files and the training records viewed showed that all staff underwent recruitment checks in line with the law and all had undertaken training, which provides information on the types of abuse. We spoke with the District Nurse to ascertain how the Home responded to concerns raised by them. The District Nurse said improvements have been made, and gave example of how the staff sought prompt advice in relation a person being unwell and had poor appetite. We read the Home’s policy and procedure for the ‘Abuse’. Whilst the policy was written in accordance with the responsibilities and actions to be taken by the Home, it did not refer to the local multi-agency protocols, consistent with the policy document ‘No Secrets’. The Deputy Manager and the Responsible Individual were strongly advised to contact the local authority to establish how the home could acquire a copy of the multi-agency policy and procedure for safeguarding adults; ensuring it is incorporated into the Home’s procedures and shared with the staff. The Registered Manager told us in writing after the site visit that they have a copy of the multi-agency policy and procedure; copy was sent to us of the revised home’s policy and procedure on abuse, which now referred to the multi-agency protocols and staff would be briefed at the next planned staff meeting in June 2008. Comments received from the health care professional: “Issues have been addressed appropriately by the care home manager. This has included further training in palliative care, catheter care and pressure area care. These areas have all improved” Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 18 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. Kibworth Court provides a clean, comfortable, homely and well-maintained environment for people living at the Home. EVIDENCE: Kibworth Court is a situated in a residential area. The home is easily accessible for people using walking aids or wheelchairs, bright and welcoming reception area. Information about the home and other publications related to care services is located in the reception, which visitors can help themselves to. There are several information boards detailing social and leisure activities and events planned at the home. There are a number of communal lounges and dining rooms are on the ground and upper floor, furnished to a good standard with complimentary décor Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 19 pictures. All the lounges have a television and music system, which was enjoyed by the people using the lounges. The information we received from the Home before the site visit indicated that there have been some improvements made to the Home. We saw the new courtyard from the reception area and a bench donated by the relatives of a person that lived at the Home. We looked at three people’s bedrooms; all of which were personalised with pictures, photographs and ornaments. The décor in the bedrooms are colour co-ordinated with the soft furnishing and furniture. All the bedrooms have ensuite facilities. Additional bathroom and shower rooms are on both floors, which are equipment with hoists and shower chairs. We spoke with two people about viewing the bedroom; both said their relatives had seen the bedroom. One person said the family had decorated the bedroom and they instantly liked their bedroom because there were familiar things such as such the Wedgwood plates. The Deputy Manager said the Home has ensured couples are able to live together and have their privacy respected. We received comments in the survey returned from a person living at the Home: “Rooms are not always cleaned to a high standard, especially en-suite”. Throughout the site visit, domestic staff and care staff were seen working in specific areas within the home. Staff wore gloves and aprons when assisting people with personal care, meals and handling people’s laundry. Staff demonstrated good knowledge and practice to prevent the risk of cross infection and using equipment safely and training records supported this. The information received from the home before the site visit stated that flooring has been replaced with a non-slip flooring to some en-suite rooms, where required; there is a programme of maintenance and all staff receive training in infection control and health and safety. On the day of the site visit the maintenance person was seen repairing and mending things around the home. We spoke with the Handy Person about the qualification and training being sourced in test electrical equipment, as stated in the information received from the Home before the site visit. The Handyperson said the Manager was still looking into course for attaining the qualification, which would be beneficial to the Home. The Responsible Individual conducts the formal monthly visits to the Home and completes a comprehensive check and report of the findings. A report of the last monthly visit showed that the Home environment is audited and identifies the areas for improvement. Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 20 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. People living at the Home are protected by good recruitment processes; staff trained and supervised, to care and support the people using the service. EVIDENCE: People living at the Home and the visiting relatives said that there were usually sufficient numbers of staff on duty: both domestic staff and care staff. We made observations of the interaction between the staff and the people living at the Home, and they appeared confident with the staff helping them with their daily care needs. We looked at the staff rota for the day, which showed the staffing structure is based around delivering outcomes for people living at the home and is not led by staff requirements. The Responsible Individual said the staffing levels and responsibilities have been structured with staff being clear about their duties such as key working a named resident and completing the daily records at the end of each shift. We spoke with three people living at the Home about their views on the staff, they all spoke highly about the staff who assisted them with the personal care and said “Praise the night staff as you can’t fault them” and “they are good to Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 21 me, I have no problems at all with the staff”. Staff wore names badges and had distinct dress to identify them as a care staff or a senior care staff. People living at the Home told us they were able to recognise the care staff and staff that cleaned their bedrooms. We viewed the records of four members of staff: care staff: senior carer and a member of the Management Team. All the files contained a completed application form, Protection of Vulnerable Adults (POVA) first check, a Criminal Records Bureau (CRB) check and two written references. This was consistent with the information received before the site visit and from discussion with staff on duty. This demonstrated that Kibworth Court has a robust recruitment procedure, based on equal opportunities policy. We spoke with staff on duty who described the induction training completed. This included moving and handling, health and safety and caring for the people living at the home with the dementia, physical disability and general deterioation in health due to old age. Staff understood importance of training linking the training to the needs of the people living at the Home. The example given related to training in ‘sensory deprivation’ shows how to provide support to promote and maintain independence of people living at the home that have poor or no sight. Staff said training is on-going and they have the opportunity to attend specialist training provided by the District Nurse. We spoke with the District Nurse who said she had been involved in training staff at the Home. The dates of training were displayed in the office, such as continence care; end of life; sensory deprivation training; catheter care and food hygiene. The staff training matrix showed the range of training provided to staff from Protection of Vulnerable Adults from Abuse; medication training; moving and handling, infection control; tissue viability, personal care, pallative care, dementia awareness, health and safety and fire risks. We spoke with the Deputy Manager about the current number of staff that have attained National Vocational Qualification level 2 in care, which was confirmed as 40 had already attained NVQ level 2 and 40 were completing the NVQ level 2 and above in care. Staff we spoke with said that they receive supervision from their line Manager and the frequency of supervision, which was consistent with supervision schedule displayed in the office and minutes of the meeting in the staff files. Staff said they could approach senior staff and management team for advice and support. Staff confirmed they attend staff meetings, which are held regularly, which enables staff to be kept up to date and promote a consistent approach as to the care and welfare of people living at the Home. This supported by the information received from the Home before the site visit. Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 22 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. People living at Kibworth Court, live in a well managed and have opportunities to express and contribute their views to influence the care they receive. EVIDENCE: The information we received from the Home before the site visit stated that the Registered Manager has attained the National Vocational Qualifications levels 4 and the Registered Manager’s Award. On the day of the site visit to the Home the Deputy Manager was in charge and confirmed she had also attained NVQ level 4. The Home is well managed and evidence of this was made through observations made and from discussion with the staff about their roles and responsibilities during the day. The management and staffing level for the Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 23 home was reflected in the staff rota viewed and the staff on duty, including domestic and kitchen staff. The information received from the Home before the site visit, which is the Home’s own assessment contained minimal information. We spoke with the Responsible Individual and the Deputy Manager in absence of the Registered Manager about the information provided, as it did not tell us about the changes made and what improvements were planned and how they were going to do this. These comments were accepted and assurance given that in future the information sent to us would be comprehensive. The information received from the home before the site visit indicated that all policies and procedures are updated and reviewed regularly. We read a sample of the key policies and procedures, and we suggested that the Home acquires the multi-agency and incorporates this into the Home’s policy and procedure. Staff demonstrated awareness of the policies, procedures and their responsibility. Staff were confident that the Registered Manager and/or the Deputy Manager would be available if there was an emergency. People living at the home said they were encouraged to express themselves views, ideas and opinions that would improve their quality of life. There are regular ‘Residents’ Meeting’, held at the home and information about the next meeting was displayed on the notice board. We read the minutes of the last ‘Residents Meeting’, which showed the discussion topics: meals, concerns, new courtyard being planned and the Activity Co-ordinator. The Responsible Individual plays an active role in the management of the home and visits the Home on a regular basis to meet with the staff, the people living at the home and their relatives and to monitor the improvements being made at the Home. There are regular monthly visits conducted by the Responsible Individual and the records of the findings are comprehensive. We read the last monthly visit report that showed that the Home is monitored and the quality delivered is measured using views of people living at the home, staff and records. People living at the home either they manage their own money, some with the support of their families and whilst others prefer to have their money held in safe-keeping by the Home, for which records of the expenditure and balances are kept. The information received from the home before the site visit stated that the servicing and testing of equipment; gas and electrical testing are carried out at annually. Risk assessments are in place for the home, the people living at the Home and the staff. Kibworth Court has a planned programme of maintenance and records of checks carried out are kept up to date. Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 24 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 3 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 Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 25 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. 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. Refer to Standard Good Practice Recommendations Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Kibworth Court Residential Home DS0000001739.V365283.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!