Care Home: Kingswood Court

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What the care home does well Generally the home was found clean, tidy and warm. Staff were working as a team and interacting with residents in a positive, dignified and sensitive manner, residents were found relaxed and looked well cared for at the home. The home assesses all prospective residents before admission to the home incorporating needs, choices and preferences. Residents and relatives have the opportunity to spend time at the home before accepting placement. The manager stated that communication is key to effective provision of good standard of care and that the home does this through regular resident/ relatives meetings to listen and act on their views, one on one meetings and supervisions, trained staff meetings and training. The manager recently introduced a memo file for staff on each floor as well as a separate memo file for trained nurses, this enables the manager to communicate important issues with staff and keep them fully informed. The manager also introduced a Handover form so that trained staff can communicate more effectively with each other. The manager believes that part of good communication is to keep staff informed of changes in legislation or policies and procedures, with this in mind the home recently introduced a risk assessment folder for all departments of the home with relevant risk assessments and policies, this is a working document that is kept updated. The home undertakes monthly reviews of residents with the key workers and comprehensive six monthly reviews including the relatives and or friends to update individual care plans. Meaningful activities are provided for service users and individual interaction is provided as necessary and in particular individuals who prefer to be in their rooms. Good meals are provided for the residents and staff ensure that meals are not hurried and residents who are unable to feed themselves are fed in a respectful, sensitive and dignified manner. A robust complaint procedure is in place and all complaints are investigated properly and action taken where required. There are ongoing training courses to enable staff to meet individual residents needs and ensure residents are protected from harm and abuse. A stringent recruitment procedure is followed to ensure that appropriate staff are employed at the home. The home is adequately staffed to include care and domestic staff. Aids and equipment are provided in sufficient quantity to assist care staff in meeting the needs of residents. To ensure that the home promotes and incorporates equality and diversity in the services, religious service or visits from religious denominations are offered to participating residents. What has improved since the last inspection? The home stated in the Annual Quality Assurance Assessment (AQAA) that along with a robust training programme all new and existing staff have received training in person centred care. The home has introduced a checking system to ensure that all care monitoring forms are completed. To ensure that the home complies with the regulation the manager stated that trained staff have been informed of the importance of sending the regulation 37 Notification to the Commission for Social Care Inspection and their responsibilities. Complaint forms are on each floor and with the existing open door policy staff, residents and relatives are able to bring their concerns.The home has started a programme of re-decoration. Fifty percent of the bedrooms have been decorated and a list drawn up of the bedroom furniture that needs replacing and rooms that require re-carpeting. The home has several informal gatherings for residents and relatives, which have a positive effect, and allows them the opportunity to raise any issues with the manager and staff. What the care home could do better: It could be better to ensure that the monitoring chart put in place to reduce/prevent pressure sore on a vulnerable resident is completed consistently. While we note that one identified resident had care plans in place to meet their needs, these care plans were last reviewed in August 2008. This means that the risk of missing the changing needs of the resident is increased. CARE HOMES FOR OLDER PEOPLE Kingswood Court Soundwell Road Kingswood South Glos BS15 1PN Lead Inspector Grace Agu Unannounced Inspection 9th January 2009 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kingswood Court DS0000020249.V373731.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. Kingswood Court DS0000020249.V373731.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingswood Court Address Soundwell Road Kingswood South Glos BS15 1PN 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) 0117 9603722 0117 9603744 kingswood.court@fshc.co.uk Grandcross Limited (wholly owned subsidiary of Four Seasons Health Care Ltd) Ms Linda De’ath Care Home 66 Category(ies) of Old age, not falling within any other category registration, with number (66) of places Kingswood Court DS0000020249.V373731.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. May accommodate up to 66 persons aged 50 years and over who are receiving nursing care. Of the total 66 persons, up to 3 persons (who must be 65 years or over) may be accommodated and provided with personal care only. Manager must be a RN on parts 1 or 12 of the NMC register Staffing notice dated 22/6/1998 applies. May accommodate one person under the age of 50, who has physical disability. This condition relates to a named person and will lapse if the person leaves the home. 4th February 2008 Date of last inspection Brief Description of the Service: Kingswood Court is a purpose built home, operated by Grand Cross Ltd, which is affiliated to Four Seasons Health Care. The home is registered to provide nursing care for 66 people over the age of 50. It has ample car parking space at the rear and a small garden in front separating it from the main road. There is access to local shops, amenities and bus routes. Accommodation is provided over three floors; each floor has its own lounge and dining area. There is level access throughout the home and a lift to each floor. Toilets and bathroom facilities are adequate for the number of residents and have adaptations to meet their assessed needs. All rooms are equipped with call alarm systems. Visitors may visit at any time. The fees charged for staying at the Home for care range from £521.07 to £600 per week. Kingswood Court DS0000020249.V373731.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. This was an unannounced inspection, which was undertaken as a part of key inspection to review the care practice to ensure that it is in line with legislation and that best practice is followed at the Home. The inspection also followed up the last inspection requirements to ensure that the action plan provided by the home on how they were to meet the requirement made at the last inspection had been fully implemented. Review of notes, discussion with the registered manager and staff showed that the home had strategies in place to meet residents’ needs. A tour of the building was undertaken and a number of records were viewed. Nine residents, and two relatives were spoken with on the day. What the service does well: Generally the home was found clean, tidy and warm. Staff were working as a team and interacting with residents in a positive, dignified and sensitive manner, residents were found relaxed and looked well cared for at the home. The home assesses all prospective residents before admission to the home incorporating needs, choices and preferences. Residents and relatives have the opportunity to spend time at the home before accepting placement. The manager stated that communication is key to effective provision of good standard of care and that the home does this through regular resident/ relatives meetings to listen and act on their views, one on one meetings and supervisions, trained staff meetings and training. The manager recently introduced a memo file for staff on each floor as well as a separate memo file for trained nurses, this enables the manager to communicate important issues with staff and keep them fully informed. The manager also introduced a Handover form so that trained staff can communicate more effectively with each other. The manager believes that part of good communication is to keep staff informed of changes in legislation or policies and procedures, with this in mind the home recently introduced a risk assessment folder for all departments of Kingswood Court DS0000020249.V373731.R01.S.doc Version 5.2 Page 6 the home with relevant risk assessments and policies, this is a working document that is kept updated. The home undertakes monthly reviews of residents with the key workers and comprehensive six monthly reviews including the relatives and or friends to update individual care plans. Meaningful activities are provided for service users and individual interaction is provided as necessary and in particular individuals who prefer to be in their rooms. Good meals are provided for the residents and staff ensure that meals are not hurried and residents who are unable to feed themselves are fed in a respectful, sensitive and dignified manner. A robust complaint procedure is in place and all complaints are investigated properly and action taken where required. There are ongoing training courses to enable staff to meet individual residents needs and ensure residents are protected from harm and abuse. A stringent recruitment procedure is followed to ensure that appropriate staff are employed at the home. The home is adequately staffed to include care and domestic staff. Aids and equipment are provided in sufficient quantity to assist care staff in meeting the needs of residents. To ensure that the home promotes and incorporates equality and diversity in the services, religious service or visits from religious denominations are offered to participating residents. What has improved since the last inspection? The home stated in the Annual Quality Assurance Assessment (AQAA) that along with a robust training programme all new and existing staff have received training in person centred care. The home has introduced a checking system to ensure that all care monitoring forms are completed. To ensure that the home complies with the regulation the manager stated that trained staff have been informed of the importance of sending the regulation 37 Notification to the Commission for Social Care Inspection and their responsibilities. Complaint forms are on each floor and with the existing open door policy staff, residents and relatives are able to bring their concerns. Kingswood Court DS0000020249.V373731.R01.S.doc Version 5.2 Page 7 The home has started a programme of re-decoration. Fifty percent of the bedrooms have been decorated and a list drawn up of the bedroom furniture that needs replacing and rooms that require re-carpeting. The home has several informal gatherings for residents and relatives, which have a positive effect, and allows them the opportunity to raise any issues with the manager and staff. 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. Kingswood Court DS0000020249.V373731.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 Kingswood Court DS0000020249.V373731.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): 1,2,3,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that residents’ needs are met through appropriate and detailed preadmission assessment. It also ensures a one-month trial and Terms and Conditions of stay. EVIDENCE: The manager stated that the home’s statement of purpose has detailed information about services and facilities to be provided. This was confirmed in the Annual Quality Assurance Assessment (AQAA). The home also has a Service Users’ Guide that is given to prospective residents and or their relatives when they visit or enquire to enable them to make an informed choice about moving to the home. The care record of one resident admitted in May 2008 was viewed. There was detailed assessment from the home to include physical, psychological, mental and social needs before the individual was admitted. This assessment was Kingswood Court DS0000020249.V373731.R01.S.doc Version 5.2 Page 10 undertaken to ensure that the needs of the resident would be met at the home. The home stated in the AQAA that it offers prospective residents a day at the home to enable the person to decide whether to stay. The home also ensures that a one month trial is offered on admission and that every resident is provided with Terms and Conditions of their stay. Kingswood Court DS0000020249.V373731.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): 7,7,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home offers care and support to residents throughout their lives and towards the end it also protects residents by reviewing their health needs and satisfactory care planning. The home ensures that residents are protected through appropriate medication administration and storage. EVIDENCE: We reviewed five residents’ care files in detail. This is to ensure that plans of care addressed the needs of the residents based on the initial assessment. The care plans included information about the physical and the psychological nursing care needs of the individuals and stated what actions staff should follow to assist the residents in order to meet their needs. All the records included an assessment of the person’s risk from falling. These assessments had been updated on a monthly basis by the registered nurses. However we noted that one resident’s care records were last reviewed in Kingswood Court DS0000020249.V373731.R01.S.doc Version 5.2 Page 12 August 2008. The registered manager stated said that the nurse responsible for reviewing the care plans had left their employment and the other nurses had not picked up the reviews. We believe that this is not a good practice because accurate information in relation to change in the needs of the individual will not be recorded and the person may not receive the care/ nursing needs that they require. The manager stated that she would review the system with registered nurses and would ensure that the care file is completed and continued monthly. There was a daily record maintained for each person whose records were seen and detailed the person’s daily health and welfare. Thorough examination of care documentation evidenced that residents are well supported with their health care requirements in order to access services. There were records of when individuals have been visited by dentist, optician’s district nurses and general practitioners. While we noted that the home has residents with pressure area wounds, the home has appropriate risk assessments and care plans in place to support the care that the individuals are receiving. There was pressure relieving equipment in place and the Tissue Viability Nurse was consulted for advice on treatment and prevention of pressure sores. The Commission will continue to monitor this situation and would require regular update from the home in relation to fewer or no pressure area wounds. We reviewed the procedures for the dispensing, administration, and disposal of medication in the Home. We observed a registered nurse on the middle floor carrying out the lunchtime drug round. A random selection of residents’ medication administration charts was looked at. There was a photograph of the residents maintained with each administration chart. Procedures for medication administration, handling, records and storage were assessed. The home had policy and guidelines on medication. A local pharmacy provides medication using a monthly monitored dosage system. A check of the blister packs indicated that medication had been administered as recorded. All medication seen was stored securely. Medicines trolleys are used to transport medications around the home. The home has a medicine fridge and temperatures are recorded daily. Controlled drugs were stored correctly and recorded in a register. Kingswood Court DS0000020249.V373731.R01.S.doc Version 5.2 Page 13 The pharmacy supplies printed medicines administration record sheets each month. Records of administration of medicines were clear. Records are kept of medicines received into the home. Waste medication is recorded and disposed of via the supplying pharmacy. Action taken by the home in relation to drug error notification was found satisfactory. Residents told us that care staff also spoke to them in a friendly and warm manner as they assisted them with personal care needs. Through observation we noted that care staff showed sensitivity and understanding of the complex needs of some of the residents living at the home. The provider invested resources on training of staff on death and dying to ensure that staff are aware of their responsibilities in terms of meeting the needs of a dying resident and at time of death. Staff demonstrated knowledge in relation to keeping information about residents confidential. Kingswood Court DS0000020249.V373731.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home enables the residents to maintain contact with families, friends and the local community. It provides meaningful activities and choice in respect of meals and meal times. EVIDENCE: Information seen evidenced that the individuals living at the home are provided with a variety of social activities and are able to participate or not. This is dependent on the individual’s choice. The home has an Activity Coordinator who is responsible for providing activities based on individual capabilities and choices. These included: bingo, crafts, cards and board games, church services, video library, library service, discussions, hairdressing/manicures and aromatherapy. Each resident has an activities record to ensure that their participation is monitored. Discussion with the manager, staff members and evidence from the visitors’ book showed that the residents maintain good contact with families and Kingswood Court DS0000020249.V373731.R01.S.doc Version 5.2 Page 15 representatives. The level of contact varies for each resident living at the home, some receive regular visitors and go out with family and others do not. The home would contact individual’s next of kin should they need to be informed of issues, which affect the well being of an individual living at the home. A tour of the building evidenced that residents were spending time in their bedrooms and the communal lounges. Daily records of care showed that residents are able to choose when to get up and retire, what to eat/drink and how they were to be assisted with aspects of their life. We observed residents having their meal at lunchtime. The meal was relaxed and residents were given the meals based on the choices they made after consultation about the meals available to them. Residents who were unable to feed themselves were given appropriate support; staff approached the residents in a sensitive manner and treated them with dignity and respect. Residents spoken with stated that they enjoyed their meal. One resident stated, “The food is always very good”. In relation to equality and diversity the manager stated that the home consulted the family of a resident from a different ethnic background on choice of food to ensure that their needs were adequately met. The kitchen was found very clean; there was a cleaning schedule in place. The home was recently inspected by the South Gloucestershire Council Environmental Services and was given a five star rating on food safety. There was a kitchen risk assessment in place. All staff working in the Kitchen have attended Basic Food Hygiene training. Kingswood Court DS0000020249.V373731.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain and are confident that their complaint will be listened to. Practices at the Home ensure protection of residents from harm and abuse EVIDENCE: The Home has appropriate procedures in place for the management of complaints. The complaints procedure was noted displayed at the entrance as well as in each resident’s care file. This document contains information about the Commission for Social Care Inspection to enable individuals to contact the Commission if they were not satisfied with the outcome of their complaint to the organisation. There were four recorded complaints since the last inspection. Records indicated that the appropriate procedure was followed and that the complaints were satisfactorily resolved. Residents’ responses at discussions evidenced that residents are aware of whom to complain to. One resident stated, “I have complained before and it was sorted by the manager”. Kingswood Court DS0000020249.V373731.R01.S.doc Version 5.2 Page 17 Staff are aware of the Whistle Blowing policy and would report any bad practices to the Manager without fear of reprisal. There was evidence of staff training in relation to Protection of Vulnerable Adults from Abuse. There is a copy of the South Gloucestershire Council policy on The Protection of Vulnerable Adults from Abuse at the Home to ensure that the Home is aware of the protocol to be followed if incidents of abuse occur. Records of recently employed staff members were viewed and contained personal information and record of identity. Other statutory information to include two satisfactory references, record of previous employment, and satisfactory Criminal Record Bureau disclosures were noted in the staff files reviewed. The Registered Manager regularly checks and updates the Personal Identification Numbers of the Registered Nurses to ensure that residents are adequately protected. Kingswood Court DS0000020249.V373731.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): 19,20,21,23,24,25, 26 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The residents enjoy a pleasant, safe and homely environment with a good standard of hygiene. EVIDENCE: Kingswood Court is a purpose built home, operated by Grand Cross Ltd, which is affiliated to Four Seasons Health Care. The home is registered to provide nursing care for 66 people over the age of 50. It has ample car parking space at the rear and a small garden in front separating it from the main road. There is access to local shops, amenities and bus routes. Accommodation is provided over three floors; each floor has its own lounge and dining area. There is level access throughout the home and a lift to each floor. Toilets and bathroom facilities are adequate for the number of residents and have adaptations to meet their assessed needs. All rooms are equipped with call alarm systems. Visitors may visit at any time. Kingswood Court DS0000020249.V373731.R01.S.doc Version 5.2 Page 19 Residents were found sitting in the communal areas, looking well looked after in their homely environment. Those found sitting in their rooms were also found relaxed and were complimentary about the home and the services it provided. At a discussion with a resident found relaxing in their room with a relative, the individual stated, “I am very well looked after. I have been in this home for many years. I am very happy here”. The home was found clean, warm, well lit and free from unpleasant odours. The clinical waste is correctly disposed of to prevent spread of infections. The home has an infection control policy. The maintenance man stated that staff record work to be done in the maintenance book and this is signed off when it is carried out. He told us that the book was up to date. The laundry area was found clean and tidy. Two laundry assistants found on duty stated that they have attended Control of Substances Hazardous to Health (COSHH) training and also infection control. The staff members were aware of residents’ choice, and privacy and ensure that incidents in relation to residents’ clothing are reported. Kingswood Court DS0000020249.V373731.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): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents enjoy a good, warm relationship with competent staff. The Home’s recruitment procedure offers protection to residents. There are adequate numbers of staff to meet the needs of the residents. EVIDENCE: During the inspection staff were able to demonstrate a clear understanding and knowledge of the individuals who use the service, and of their role in the home. It was evident from interactions between staff and residents during the inspection that staff have developed positive relationships with the residents. Evidence from the records seen showed that there were three registered nurses and eleven carers in the morning between 8am and 2pm, the manager and one housekeeper, two domestics, three kitchen staff, two laundry staff and a maintenance person. Staff rota evidenced that there are adequate numbers of staff in the evening and at night. The manager stated that there was an extra member of care staff is occasionally used in the morning to cover sickness in order to avoid using Kingswood Court DS0000020249.V373731.R01.S.doc Version 5.2 Page 21 agency staff that are not familiar with the routine of the home. Staff spoken with confirmed this. The manager believes very firmly in investing in people through a very robust training programme. She stated that if you invest in good training you ensure that the staff have the knowledge base to care for residents with dignity. The training programme allows for discussion and group work, which asks the staff searching questions about dignity, privacy and issues associated with caring for vulnerable adults. The manager believes also that the training provided at Kingswood Court is good and intends to expand on the training programme this year. All staff have completed core training, which includes Moving and Handling, Fire Awareness and Health and Safety. There was also evidence of, Bedrail, Catheter, communication training and a Makaton workshop. All staff have attended the Vulnerable Adults Alerter training, with an update on 15 January 2009. The manager said this is discussed at supervision. Registered Nurses and some senior carers have attended training in wound care and pressure injury in response to the last inspection requirement. Four Seasons Health Care recruitment and selection policies were in place at the home. The home keeps secure information and documents in respect of staff working in the home. These, include two satisfactory references, proof of identity, and Criminal Record Bureau disclosure (CRB). Kingswood Court DS0000020249.V373731.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): 31,32,33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home benefits from good leadership and management; its practices offer protection to the health and safety of residents. EVIDENCE: Ms Linda De’ath is a competent Manager and has been at the home for about 12 months. Ms De’ath is a registered nurse and has completed Registered Managers Award. She has attended many other courses to include City and Guilds Teaching Qualification, National Vocational Assessors Award A1/A2 and Trainer Award in Abuse awareness training to enable her to support staff members in delivery of care and protection to the people using the service. On the day of inspection there was a friendly and interactive atmosphere in the home. Residents looked well cared for and were seen talking to staff in an Kingswood Court DS0000020249.V373731.R01.S.doc Version 5.2 Page 23 informal way. This is evidence of the Manager’s leadership and management style. Staff spoken with were very complimentary of the Manager’s ability to manage the home. The home has put in place several monitoring tools. Four Seasons has extensive auditing tools for the manager to use but, the manager introduced a daily checking form for the care staff to complete, this highlights if the residents needs are being met. For example: fluid balance chart or repositioning charts are being filled out consistently. While this is a very useful tool, which could highlight poor practice, we noted that one individual’s turning chart was not completed consistently on one occasion and could give inaccurate information about the individual’s health. The manager stated that she would ensure that this would not happen again. The manager told us that the home organises informal residents meetings in the form of a cheese and wine evening entertainment and uses the forum to enable people to raise any concerns that they may have regarding the services provided. The next meeting of entertainment and quiz evening is n Accidents to residents were recorded and reviewed and where appropriate care plans and risk assessments were reviewed to ensure that needs are adequately met. The manager stated that she undertakes risk-monitoring meetings weekly with the trained nurses and reviews the statistics monthly to enable her to write a memo to care staff in relation to the accidents. The Manager stated that generic risk assessments of the home will be undertaken and she would ensure that individual risk assessments in relation to residents’ rooms would be undertaken and included in their files. Other measures in relation to resident’s health and safety to include maintenance of fire alarm systems, smoke detectors, emergency lighting, hoist servicing passenger lift and Nurse Call system were in date. The home has policies and procedures to include staff training in health and safety and manual handling. Records in relation to residents’ money were satisfactory. Staff spoken with stated that they receive regular supervision to enable them to perform their duties effectively and deal with any areas that need improvement in relation to meeting the needs of the residents. Kingswood Court DS0000020249.V373731.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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 3 3 3 3 3 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 3 3 X 3 3 3 3 Kingswood Court DS0000020249.V373731.R01.S.doc Version 5.2 Page 25 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. 1. Standard OP7 Regulation 15 Requirement Care plan must be reviewed regularly to ensure that information is available when needs change. Identified residents turning chart must be completed as planed to reduce the risk and prevent pressure sores. Timescale for action 09/01/09 2. OP7 15 09/01/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kingswood Court DS0000020249.V373731.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Kingswood Court DS0000020249.V373731.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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