Care Home: Kingshill

What the care home does well Kingshill is a well-managed and well run home ensuring a high standard of care for the people living there.Residents have access to everything they might need to live a comfortable life. If something is needed, relevant to a person`s health and well-being arrangements are made for it to be obtained. The premises are clean and safe and the standard of accommodation is very good, there are effective systems in place for keeping the home maintained to a good standard. There have been few staff changes, so residents are looked after by people they know and trust. Staff are well trained and show commitment towards giving good care to the residents. The staff group views training and development positively, and there is general willingness to learn. Records are kept to a good standard, the office is well organised and everything is to hand. The home is exceptionally good at seeking the views of residents, staff and others so that the service can be further improved. The service is not complacent and looks to continually improve. Relatives are made welcome and any suggestions they put forward are always considered. What has improved since the last inspection? The care plans were better organised, with some old paperwork taken out and archived. This makes the plans easier to work with. Several areas of the home had been decorated, including the lounge, dining room, corridors and hall and stairs. New pictures have been hung on the walls. The second edition of the Kingshill magazine is up and running with both staff and residents input and informs people of past, present and future events. More residents are going to college and have become more involved with groups such a gardening. What the care home could do better: That staff sends a report of all incidents to the CSCI which include injuries and accidents that affect the well being of residents and staff. The CSCI had been notified of some incidents but not all. CARE HOME ADULTS 18-65 Kingshill Kingshill Court Standish Wigan Greater Manchester WN6 0AR Lead Inspector Unannounced Inspection 3rd March 2008 09:30 Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingshill Address Kingshill Court Standish Wigan Greater Manchester WN6 0AR 01257 421332 01257 427681 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) Making Space Mr Benjamin Charles Ogden Care Home 15 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (15) of places Kingshill DS0000005742.V359930.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: Mental disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 15 Date of last inspection 26th July 2006 Brief Description of the Service: The company Making Space owns Kingshill Care Home. The home is a purpose built two-storey building that offers personal care and support for up to 15 adults, who have been diagnosed with a mental disorder. Although the home is mainly a care home for younger adults in the 18 –65 age range there are some adults who have lived at the home for a number of years who are now over 65 years of age and as long as the home can meet their individuals needs they are able to remain at Kingshill. The home provides 15 single rooms, a lounge, conservatory, dining room, communal toilets and bathing facilities. There is a residents kitchen and laundry facilities. The home does not have a passenger lift, however bedrooms and bathrooms and toilet facilities are available on both floors. There is a large private garden at the rear and seating at front of the home. Kingshill is set in its own grounds in a residential area of Standish. Wigan and Standish town centres are easily accessible by public transport. There is car parking to the front of the home. At the time of the inspection the weekly fee charged is £371:37 per week. Additional charges were made for hairdressing, holidays and continence products. Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 5 Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means that people who use this service experience excellent quality outcomes. This inspection which included a site visit that the home did not know was going to happen was conducted over a five-hour period. When we arrived the home’s manager was on leave, the deputy manager assisted with the inspection. The home’s manager had been contacted and chose to cancel his day off and come in to work. Part of the time was spent in the office looking at the information the home holds on residents (care plans) and other records the home needs to keep to ensure the home is properly run. The inspector spoke with residents and staff throughout the course of the day. Prior to the inspection the manager was sent an Annual Quality Assurance Assessment form (AQAA). This tells the inspector what the home does well at, what has improved since the last inspection and in what areas there is still room for improvement. To find out more about the home, comment cards were sent to residents, relatives, staff and other people who visit the home such as doctors and district nurses. Nine residents, seven relatives, thirteen staff returned comment cards. There was no added comments made on the cards from residents, however all indicated that they were happy living at the home and with the facilities and services provided. One relative said,” Kingshill does everything to care for and look after my relative. They do everything well and they are a very good caring home”. Another said, “ They treat us as one of the family, we could not wish for better care”. Other comments made included, ‘they always treat my relative with dignity and respect and sees to his individual circumstances and care’. Staff comments were positive with regard to training, support from the management, recruitment and induction. Some comments have been made that residents would benefit more with regard to outside interests and activities if there were more staff. One member of staff said,” I am proud to be employed by Making Space. At Kingshill I take pride in the staff team, this reflecting in the stability of the service users”. What the service does well: Kingshill is a well-managed and well run home ensuring a high standard of care for the people living there. Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 7 Residents have access to everything they might need to live a comfortable life. If something is needed, relevant to a person’s health and well-being arrangements are made for it to be obtained. The premises are clean and safe and the standard of accommodation is very good, there are effective systems in place for keeping the home maintained to a good standard. There have been few staff changes, so residents are looked after by people they know and trust. Staff are well trained and show commitment towards giving good care to the residents. The staff group views training and development positively, and there is general willingness to learn. Records are kept to a good standard, the office is well organised and everything is to hand. The home is exceptionally good at seeking the views of residents, staff and others so that the service can be further improved. The service is not complacent and looks to continually improve. Relatives are made welcome and any suggestions they put forward are always considered. What has improved since the last inspection? What they could do better: That staff sends a report of all incidents to the CSCI which include injuries and accidents that affect the well being of residents and staff. The CSCI had been notified of some incidents but not all. Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 8 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. Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 9 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 Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Detailed information is available at the home to ensure that prospective residents and their supporters can make an informed decision about the suitability of the home. EVIDENCE: In the homes foyer there is a wide range of information. The statement of purpose and service guide is available and gives detailed information about the home, the services and facilities available and about the staff. Further information is also offered to prospective residents and their supporters, which gives an insight in to some different types of mental illness and their symptoms of which some of the residents at Kingshill could be admitted with. We looked at records the home holds for two of the residents. One being the last person that had moved into the home. Information was seen to provide a good overview in relation to individuals emotional, physical and social care needs. Details included information on the individual, names of relevant professionals involved with the care Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 11 management, social history and current medication. Other areas of need, issues and goals were documented and included: personal care, accommodation, domestic skills, activities and daily life, religious and spiritual needs, education, social skills, personal relationships and individual strengths. Prior to any resident moving into the home a full assessment is carried out by a social worker and by either the homes manager or one of the deputy managers. This is to ensure not only have the staff got the necessary skills and experience to meet the needs of the resident but also the prospective resident will adapt to the home and with other residents already living there. Assessments were seen in both residents files looked at. Areas of potential risks were also identified for example violence to staff and residents, smoking, going out unaccompanied (the home has small identification cards which details the name of the home and the telephone in case of emergency), risks of falls, moving and handling (if required). The home welcomes prospective residents and their supporters to visit the home prior to making a decision to move in. They are encouraged to spend some time at the home, look around, see their room, stay for a meal and get to know the staff and residents and ask any questions to reassure them. All residents are provided with a written contract/statement of term and conditions. These were available for inspection. Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information details the support needs of residents and how this care is to be provided. Residents expressed they were well cared for and were involved in making decisions about their lives. EVIDENCE: Information about the residents is held in a secure location. The information was clear and concise and includes: a full care plan, risk assessments, residents profile, medical notes, any appointments and correspondence. The files were organised and some of the old information had been archived, making the files easier to work with. Daily records of events are kept using a separate system. One resident spoken with was aware that the home holds information and records about the individual. Residents are encouraged to make decisions about their lives and are offered all the support and assistance they need, for example one resident is taken to Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 13 college and collected by staff until confident to make the journey unaccompanied. Another resident has overnight stays with a friend; all staff was aware of this and supported this. All staff is aware that any intervention provided by staff to minimise risk is recorded on file along with detailed information on how the resident is to be supported. All residents are encouraged to be involved with the development of their plans. Both files seen had been signed and agreed by the resident. Information provided on AQAA informed the inspector that key workers had now a greater involvement in the development of the care plan and with the risk assessments. There was evidence that showed that the home works well with outside agencies and the hospital Consultants continue to provide on-going support and advice to the home. Any changes to the individuals needs recommended is documented and acted upon. Regular reviews are held to ensure that all aspects of health, support, care and well being are given and maintained and the individual remains happy, well cared for, valued and respected at Kingshill. Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, 16 and 17 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Daily routines promote residents’ independence and choice. Residents are actively supported to maintain contact with their family and friends. EVIDENCE: Daily routines reflect personal choices and preferences of residents. Each is encouraged to access the wider community enabling them to learn new skills and develop other friendships. Some residents access the local college and various clubs. This provides a fairly structured week taking part in a variety of activities. One resident is learning maths and on other days helps at a local clubhouse where she bakes, works the till and takes dinner orders. On Saturdays she goes out with people from the club to various places such as Southport, shopping in Manchester, pub lunches or a trip to the cinema. Another resident told the inspector about his enjoyment for gardening and the Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 15 group he attends. The homes greenhouse has been replaced with a new one and he was looking forward to growing more things when the time is right. Two residents attend ‘Steps for Health’ helping them to keep fit, and the company run a number of ‘Quit Clubs’ in the area, which are there to help people stop smoking. Other residents at the home choose a more relaxed routine spending the majority of time at the home. There are still plenty of things for them to do within the home. One resident told the inspector that she was looking forward to a holiday in Blackpool in April, with her key worker. Each resident has access to local amenities and services such as local shops, pubs, doctors and banks which is seen as a positive step in involving the residents in becoming active members of their local community. Some residents get the local bus into Wigan to go shopping. There is no one at the home in paid employment; this is an area that the manager is looking into. Staff were observed interacting with the residents, relationships were relaxed and residents appeared very much at ease. Contact with family and friends are maintained with visits taking place both to and away from the home. The family of one resident visits the home every week and stays most of the day and has meals and drinks with the resident. Some residents go out to visit their family at home for the day. Another resident has overnight stays with her boyfriend; these are usually set nights and are important to this young person. Any changes to these arrangements are agreed and discussed by all parties. Residents are offered a variety of meals and encouraged to follow a healthy diet. Breakfast is served on a flexible basis so residents can have a lie in if they wish. There are choices available at every meal. One resident had had her lunch in town whilst out shopping. In the main the residents dine together in the main dining room. The home has an independent kitchen; residents with the help of staff can make a range of dishes. Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to maintain effective working relationships with mental health professionals who provide a positive support network for residents ensuring their health and well being is maintained. EVIDENCE: The staff fully supports residents in maintaining their heath and well being. Action is taken if the home is concerned in any way about any changes in general health or behaviour and the relevant professional consulted. Residents have access to all NHS entitlements such as doctors, dentist, optician and chiropody. Appointments are made as and when required. Where a resident would require support, a member of staff would escort them. Staff is on hand to provide personal care and support when needed and as agreed. This is dependent on individual needs. In the main residents are prompted in maintaining their own personal care and appearance. Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 17 We used the same two care plans as previously examined to check that medication had been given and recorded correctly on the individuals drugs record. The medication had been given and recorded and the correct number of tablets remained. There were no discrepancies identified. Currently the home looks after and administers all the resident’s medication; there is no one at the home who self medicates. Residents’ medication is regularly reviewed with health care professionals ensuring the stability of their mental health. Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 were assessed Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home holds clear policies regarding complaint and adult protection, ensuring that residents were listened to and protected. EVIDENCE: All residents are provided with a copy of the complaints procedure, which has recently been updated. Information on the returned AQAA indicated that one area where they could do better is to increase resident’s awareness of the complaints procedure and the abuse policies and procedures in place. The complaints file was available for inspection; there had been no complaints made to the manager of the home since the last inspection and no complaints have been brought to the attention of CSCI. All staff has now received training in the protection of vulnerable adults. There have been no safeguarding referrals made. The home oversees the personal monies for most of the residents. Records are made of all transactions to show what money has been provided and is signed by the residents. Residents are asked to bring back any receipts of transactions. Some residents go to the bank themselves, others with staff assistance. Using the same two care plans we had already looked at the cash and records were checked and were found to be in order with the written record. Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 19 Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26 and 30 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Kingshill is a comfortable, clean and homely place, which meets the needs of those living there. EVIDENCE: Kingshill is a purpose built home that is sited off the main road in Standish. The home is in a residential area and has been built in the same style as the surrounding properties. Accommodation is on two levels and compromises of: on the ground floor the main lounge and dining area with a conservatory, the main kitchen, activity room and a resident’s kitchen. Bathrooms and toilets are on both floors. All bedrooms are single; none have en suite facilities. The home does not have passenger lift to access the first floor. The home is spacious, homely and well maintained. In the last twelve months there has been a full refurbishment of the home. The main lounge area is well equipped with a large television, DVD and a music centre. The home has a Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 21 quiet room, therapy room for Reiki treatment and beauty treatment. There is well-stocked activity room and a computer. Bathrooms are domestic in style and tastefully decorated to enhance a relaxed atmosphere when bathing. We asked to see the bedrooms of the two residents whose care plans we had looked at. One resident showed the inspector his room, which was nicely decorated and the resident had brought his own personal possessions, including his guitar and his telescope. The resident told the inspector, he liked his room and he had everything he needed. We did not go in to one room as the resident was out of the home and therefore we could not ask his permission to look in his room. Another resident kindly showed the inspector her room and again this was very comfortable, very feminine and had lots of personal belongings. When a new resident moves into the home they have the option to change the décor to a style and colour of their own choice. Residents are encouraged to keep their own rooms clean and tidy, staff is on hand to assist as and when required. Some residents are able to do their own laundry others require assistance. The home has a domestic kitchen for residents to practice their cooking skills. The home is set in its own grounds with a private enclosed garden space at the rear. There is seating area at the front of the home for residents to sit outside. The home is well maintained both internally and externally. The home has domestic and kitchen staff that carry out the majority of the cooking and cleaning. The home is spotlessly clean, odour free and a credit to the domestic team. Kingshill DS0000005742.V359930.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents can be sure that their needs can be met by good staffing levels with a competent, committed, experienced and a well trained staff team. EVIDENCE: Staffing levels on the day of the inspection were sufficient to meet the needs of the residents. Over the last year there has been a reduction in the numbers of agency staff used and an increase in staff having gained NVQs, which can only benefit the residents living at the home. If agency staff had to be used the home requests that it is the same staff that is familiar with the home and with the residents who attend. There is two staff on duty, one waking and one on sleeping in throughout the night. Staff are all clear of their roles and responsibilities and each resident has a key worker who takes responsibility for ensuring they that they have everything they need. Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 23 Several of the staff had worked at Kingshill for a number of years, this provides good, consistent and reliable care for the residents who know the staff well and can trust them. From the inspectors’ observations, staff morale appeared to be good and the staff team appeared genuinely happy to be working at the home. The pleasant and cheerful manner of the staff creates a warm and welcoming atmosphere, which is evident on entering the home. On the day of the inspection a student had started her placement working at the home. Staff was observed starting her first day induction programme. Any new staff undertakes a full induction programme on commencement in work as set out by Skills for Care (formerly known as TOPSS). Staff spoken with said they were offered a lot of training relevant to their work. Mandatory training is also completed and updated as required. There was evidence in staff files of valid training certificates. A copy of each member of staff’s employment file is kept at the home in a secure location. A detailed copy is also held at head office. We looked at three staff files; all files were complete and up to date. Files contained an application form, references, statement of terms and conditions and other forms of identification. All staff had had a criminal records bureau check and disclosure numbers were shown to the inspector. Kingshill DS0000005742.V359930.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Kingshill is well run by a well-qualified, suitably experienced and competent manager. Residents can be sure their best interests will be the central focus, with a positive and inclusive approach to making the service better. EVIDENCE: Management arrangements within the home have remained stable. The management team have a good awareness and understanding in relation to the needs of residents living at the home. The manager is committed to his own training and that of his staff team and sees this as an essential element to delivering good quality care for residents. Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 25 There are clear lines of accountability and all staff are being encouraged to expand their skills and different tasks have been delegated to them, such as, for some staff an involvement in record keeping. The way in which the home is run is open and transparent. The manager operates an ‘open door’ policy so that he may be approached at any time by staff, residents or their families. Monthly monitoring visits by a member of senior management are undertaken and written reports were available for inspection. The home has regular staff and residents meetings, the minutes of which were available for inspection. The home also liaises with a local advocacy group who attend residents meetings. Quality assurance surveys take place twice a year ensuring anonymous feedback from residents. The February 2008 homes magazine provides up to date information and news about what is going on at the home and with the company. Both residents and staff had made valid contributions to the magazine. Information was provided on the AQAA with regards to health and safety checks. Details were confirmed during the visit and up to date certificates were in place. Further in-house checks are carried out by staff within the home with regards to fire safety and the general environment. Any accidents, incidents or injuries were suitably recorded and the CSCI had been informed in some cases but not. This was discussed with senior staff who assured the inspector that this would be rectified and the CSCI would be informed of all incidents that affect the well being of residents and staff. Kingshill DS0000005742.V359930.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 3 2 3 3 4 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 3 26 4 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 3 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 x 3 x x 3 x Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 Kingshill DS0000005742.V359930.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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. 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