Care Home: Kiniths House

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What the care home does well The service continues to provide people with a homely and comfortable place to live. Suitable systems are in place for the control of infection and the servicing of appliances and equipment to ensure a safe environment is maintained. People receive support from a team of trained staff who know their needs and personal preferences. Regular consultation takes place with individuals about their needs and healthcare checks are arranged to ensure their physical and emotional needs are being appropriately met. The service provides people with support to maintain contact with family and friends and participate in community-based activities to enable them to develop their independent and social skills and interests. Risk assessments are carried out to suitable strategies are identified to promote independence and keep them safe from harm. People are provided with a range of opportunities to participate in the day-today running of the home. They are encouraged to express their views and the service addresses any concerns that are raised. What has improved since the last inspection? The service has reviewed its Statement of Purpose and Service User Guide. The manager is planning to produce these in alternative formats to provideKiniths HouseDS0000071454.V374817.R01.S.docVersion 5.2better access to information for people who use different methods of communication. Work continues to be carried out in implementing a person-centred approach to care planning. Information is available to staff and training has been arranged. Care plans are being reviewed regular involving the individual, their relatives and relevant health and social care professionals to ensure people`s needs continue to be met. Suitable recruitment procedures are followed to protect the well being of people who live at the home. Improvements have been made to application forms and now require more information about a person`s employment history and referees. However, the manager should improve recording for the verification of references and discussions held to clarify information provided to them by the applicant. What the care home could do better: The service provides newly appointed staff with an in-house induction programme to meeting people`s needs and the service`s policies, procedures and work practices. However, a more comprehensive programme needs to be introduced that meets the Skills for Care specification and timescales. At our previous visit individual supervision sessions where regularly held with staff. This should be re-introduced to ensure each member of the staff team is fully supported to meet the needs of the people living at the home. Improved systems have been introduced for occasions when medication is administered outside the home and a recording format produced. Further work is needed to ensure the format allows an accurate audit to take place of medication removed from the home. A written procedure for taking medication out of the home needs to be produced for staff to follow. The service`s policy on the use of restraint needs to be reviewed to ensure the information is consistent with expected practice and provides clear guidance for staff to protect people potential harm. A comprehensive quality assurance system should be produced to enable the service to effectively monitor and review its own performance and identify plans for its future development. Key inspection report CARE HOME ADULTS 18-65 Kiniths House 33 Kiniths Way Halesowen West Midlands B62 9HJ Lead Inspector Linda Elsaleh Unannounced Inspection 3rd April 2009 10:30 Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kiniths House Address 33 Kiniths Way Halesowen West Midlands B62 9HJ 0121 602 1279 0121 602 4216 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) Kiniths House Ltd Ms Lindsay Denise Price Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disabilities (LD) 9 The maximum number of service users to be accommodated is 9. Date of last inspection 18th September 2008 Brief Description of the Service: Kiniths House is a large traditional detached property. It is located in a residential area of Halesowen, with easy access to local amenities such as shops, pubs, post office and public transport. The same family has owned the home since it opened in 1986. It provides a service for up to 9 younger adults who have varying degrees of learning disabilities. There is off-road car parking at the front of the property and a pleasant courtyard at the rear of the premises. The communal areas comprise of small reception lounge, main lounge, conservatory/dining area, kitchen, laundry, bathing and toilet facilities, one shared and seven single en-suite bedrooms. Information about the home and the service it provides are available in the Statement of Purpose and Service User Guide. The manager should be contacted for the current fees charged for this service. Kiniths House DS0000071454.V374817.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 that the people who use this service experience good quality outcomes. This unannounced inspection was carried out on 3rd April 2009. The purpose was to assess the service’s performance against the key standards in the National Minimum Standards for Care Homes for Adults. Our findings are based on the information received by the Commission for Social Care Inspection (CSCI), examination of relevant records and documents kept at the home and discussions with the manager, staff on duty and people who live in the home. The atmosphere within the home was relaxed and friendly. A tour of the premises found it to be suitably furnished, clean and tidy. People we spoke to expressed satisfaction with all aspects of the care and support being afforded to them. What the service does well: What has improved since the last inspection? The service has reviewed its Statement of Purpose and Service User Guide. The manager is planning to produce these in alternative formats to provide Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 6 better access to information for people who use different methods of communication. Work continues to be carried out in implementing a person-centred approach to care planning. Information is available to staff and training has been arranged. Care plans are being reviewed regular involving the individual, their relatives and relevant health and social care professionals to ensure people’s needs continue to be met. Suitable recruitment procedures are followed to protect the well being of people who live at the home. Improvements have been made to application forms and now require more information about a person’s employment history and referees. However, the manager should improve recording for the verification of references and discussions held to clarify information provided to them by the applicant. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 7 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 Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 People using the service experience good quality outcomes in this area. The service has reviewed its Statement of Purpose and Service User Guide. People would be better supported in making an informed choice about where they wish to live by being able to access information about the home in alternative formats. Systems are in place for assessing the needs and aspirations of people who may wish to come and live at the home to ensure the service is able to meet these. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is a Statement of Purpose and Service User Guide. A copy of each document was provided to us by the manager and both were last reviewed in October 2008. These are not currently provided in alternative formats. The manager told us the service does intend to produce both documents in easy to read and alternative formats in the future. This will provide people who may Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 9 wish to live at the home with better access to information in order for them to make an informed choice about where they wish to live. At the time of this visit there were six people living in the home. There have been no new admissions for over four years. Three of the six people living at the home have been resident for 22 years. Information provided by the home states its referral and admission procedure was reviewed in April 2008. The manager told us as well as the care needs assessment provided by the funding authority the service carries out its own assessment before a placement is agreed. This includes giving consideration to the compatibility of the individual with the existing group of people who live in the home. Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 People using the service experience good quality outcomes in this area. Peoples needs and personal goals are reflected in their care plans. They are encouraged to participate in decisions about their lives and are supported to take risks as part of an independent lifestyle. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The service produces a care plan for each person living in the home. These identify clear objectives, with long and short-term goals, and details of how the person’s needs are to be met. The manager has implemented a personcentred approach to care planning. Information on person-centred planning is made available to staff and training has been arranged. There are systems for recording each person’s progress and these are used for in-house monitoring Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 11 and to inform the review process. Review meetings are held to discuss care plans with the individual and people who are important to them, such as their relatives and other professionals. We were told the service operates a ‘no restraint’ policy. However, the document states “...except as a last resort.” We discussed a recent health care assessment for a person living at the home. This identified an increase in episodes where s/he becomes agitated. In view of this information the responsible person and manager were advised to review this policy and strategies for responding to behaviours of agitation that may lead to people being at risk from harm. People are actively encouraged to make their own choices and decisions. They told us they are provided with advice and support from staff to help them live the life they choose. Two people told us about plans for their bedrooms to be decorated soon and their choice of colour scheme. They also like meeting together with staff to suggest ideas for the day-to-day running of the home, activities and holidays. A record is kept of these meetings and displayed on the notice board. This shows us people are actively encouraged to express their views. Staff told us residents enjoy spending time together and planning group activities such as the play they performed for relatives and friends over Christmas. Individual risk assessments are carried out where concerns have been identified for potential harm, such as mobility, bathing and mealtimes. These are kept on the person’s file and regularly reviewed to ensure any changes to risk and how these are managed are updated. A risk assessment has been carried out where a person travels unescorted to her/his work placement. The management team has attended training in risk assessments. Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 11, 12, 13, 14, 15, 16 & 17 People using the service experience excellent quality outcomes in this area. People are supported to take part in appropriate activities and to maintain links in the local community. They have appropriate relationships and their rights are respected. They are provided with a choice of healthy diet and a pleasant atmosphere to enjoy mealtimes. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: All people are encouraged in their personal develop and provided with opportunities to develop their independent and social skills. Each person has an individual programme. One person attends a day centre and helps out at a home for older people one day a week and at a children’s centre on another day. S/he spoke to us about how much they enjoy helping others. Another Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 13 person works in an office one day a week as well as attending a day centre during the week. S/he told us one of their tasks at work is to make drinks for the visitors. Others also have similar week day programmes. People are encouraged to maintain contact with others who are important to them and are supported by staff to make telephone calls or write letters. A list of family birthdays and special events are kept on each person’s file. The key worker supports them to buy a card and choose a present. Family and friends are welcome to visit the home at any time and enjoy events put on for them by the residents. A variety of board games are available and some people have entertainment equipment in their bedrooms such as a television, music centre and/or a computer. People said they enjoy a good social life and the home arranges trips for them. One person told us how much they enjoyed their holiday last year and “can’t wait for the next one”. The routines in the home are flexible in order to meet people’s individual needs and preferences. They choose the clothes they want to wear and when to get up and retire to bed. People’s right to privacy is respected. We saw one person being given her/his mail to open and others going in and out of their bedrooms. Individuals’ preferred routines are recorded on their care plans. We chatted to people about meals and mealtimes over a cup of tea. They told us they like the meals provided. A menu booklet is produced in a pictorial format for people to refer to if they wish. A staff member consulted with each resident about their mid-day meal. Mealtimes are regarded as a social occasion and people usually eat together at the dining table in the conservatory. The home does not employ catering staff. Meals and snacks are prepared by the care team in a well-equipped kitchen. Arrangements have been made for a new member of staff to attend basic food hygiene training and for another to update her/his training. This training has been attended by all other members of staff. Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People using the service experience good quality outcomes in this area. People living in the home are provided with personal support to meet their individual needs and preferences. The service consults with health care professionals to ensure their physical and emotional health care needs are met. There are procedures and systems are in place for ensuring current medication is managed safely on people’s behalf by staff trained to do so. The system for occasions when people need to take medication when away from the home is being improved to ensure their well being is more fully protected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People’s care needs and how they wish to be supported are included in their care plans. One person’s plan show s/he bathes independently. Others require different levels of assistance/support from staff. People told us staff Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 15 always helps them and know how they like things done. Staff we spoke said they follow the care plans and ensure a person’s dignity is respected when they are being assisted with their personal care. For example, personal care is always provided in the privacy of the person’s own room or bathroom. Visits made by health care professionals also take place in private. There are good systems in place to ensure people’s health care needs are met. Records are kept of visits made to or by health care professionals. This shows us people receive regular routine healthcare checks from professionals such as their doctor, dentist, optician and chiropodist. The home also ensures steps are taken to monitor people’s well-being and, where appropriate, preventative measures are taken. For example, weight checks are undertaken, where applicable, and a nutritional screening tool is used to identify what action should be taken in the case of significant loss or gain in weight. The home seeks medical advice for any aspects of a person’s health they are concerned about. A re-assessment of one person’s mental health needs has recently been carried out by her/his psychologist. Five of the six people living at the home have medication prescribed for them on a regular basis. The home looks after the medication for these people and suitable arrangements are made to ensure medication is stored safely. The records show staff responsible for managing medication had been trained to do so. Individual medication administration record (MAR) sheets are kept and appropriately completed. The service has a system for medication needed to be taken when the individual is away from the home, for example medication required to be taken when a person is at day centre or away on holiday. However, a procedure for this is not included in the home’s policy. The need for a written procedure for staff to follow was discussed with the manager and for the recording process to be improved to enable accurate auditing to take place. The manager told us medication is soon to be provided by the pharmacy in a monitored dose system. She has informed the pharmacist the need for the system to allow for some medication to be taken away from the home and will seek advice on suitable procedures and recording methods. She has also arranged for the pharmacist to provide training for staff in the use of the monitored dose system. Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People using the service experience good quality outcomes in this area. This home has systems to ensure that the views of the people who live there are listened to and acted upon, to ensure they are provided with a service that meets their needs and preferences. Safeguarding procedures are in place and training is provided to staff to protect people from abuse, neglect and self-harm. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Information about the home’s complaints procedure is available in the Statement of Purpose and Service User Guide. The copy we were provided with shows the contact details need to be updated. Our records show no complaints have been reported to us about this service. Information provided by the service also states no complaints have been received by them. People we spoke to told us they would speak to a member of staff if they were unhappy or worried about anything. They said they were confident the home would appropriately deal with any issues they might raise. Two people told us Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 17 “we talk to staff if we are unhappy about anything” and another said “they are very helpful and look after us well”. Policies and procedures for the safeguarding of vulnerable adults are available in the home and adult abuse awareness training is provided for staff. There have been no reported adult protection issues and no concerns were identified during this visit. People are supported to manage small amounts of money. Records are kept for personal allowances managed by the service on people’s behalf. Two members of staff sign each record and receipts are obtained for all purchases. The manager regularly audits these records and does not act as appointee for any person living at the home. Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People using the service experience good quality outcomes in this area. The people at this home live in a homely, clean, safe and comfortable environment which is well maintained and where there are good arrangements for infection control. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is a limited amount of off-road parking at the front of the premises. The rear garden is an attractively landscaped courtyard with wooden decking, stepping stones and pebble areas decorated with assorted ornaments and plant pots. The small fishpond has a suitable guard to minimise the risk of any accidents occurring. Staff said trips to garden centres will be arranged over Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 19 Easter so people can choose new plants. One person said s/he “likes picking plants and looking after them”. The communal areas consist of a small reception lounge, main lounge and conservatory where meals are served. All areas are suitably furnished and decorated. There is a notice board in the hall providing information on subjects such as activities and skills for life, some of which are provided in pictorial booklets. The bedrooms were not seen during this visit. However, people told us they like their rooms. One person told us s/he still has a personal computer in his bedroom and another resident also has one. Two people, who share a bedroom, continue to be happy with this arrangement. The manager told us plans were being made for two bedrooms to be re-decorated and was consulting with the individuals about the colour scheme and soft furnishings. Additional electrical sockets have yet to be fitted in two vacant bedrooms. The manager is aware arrangements should be made for this work to be carried out before these rooms are occupied. The laundry area is situated at rear of the premises. Procedures and guidance for the prevention and control of infection was last reviewed in April 2008 and training is provided for staff. Staff were observed wearing protective clothing when carrying out cleaning duties. The home was clean, tidy and free of malodours throughout this visit. Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 People using the service experience good quality outcomes in this area. People are supported by a stable staff team that are competent and appropriately trained to meet their needs. Suitable recruitment procedures are followed to protect people’s best interests and well being. The service provides newly appointed staff with an in-house induction programme. However, an induction programme that meets the Skills for Care specifications and timescales should be provided to ensure they receive a planned approach to understanding people’s needs. Suitable training programmes continue to be provided to support staff meeting people’s needs. However, a planned programme of regular supervision should be re-introduced to support the staff in carrying out their duties, discuss practice issues and identify future training needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 21 The team is made up of staff that have different life experiences. The majority have several years experience of working with people with learning disabilities. The home provides all staff with training in the National Vocational Qualification (NVQ) Level 2 and includes the relevant elements for working with people with learning disabilities. Seven staff holds a NVQ qualification. Two members of staff are working towards achieving Level 2 and three have almost completed the Level 3. The service does not employ the services of agency staff. Absences are covered by the team to ensure people receive a consistent level of care from the staff they know. We looked at the recruitment records for the most recently appointed member of staff. This showed all pre-employment checks had been carried out. The application form has been revised to include details of full employment history and contact details for referees. The manager is advised to review the recording formats used in the recruitment process to include the verification of references and details of relevant discussions held with candidates to clarify information in respect of their application. A Common Induction & Foundation programme which meets the Skills for Care specifications and timescales has not been provided for the most recently appointed person. However, there is a brief record of the in-house induction programme that has been carried out with her/him. The manager told us the induction programme includes a period of close supervision by her or a senior member of staff when the person was on duty. There is no record of this or planned supervision sessions being provided. A review of the service’s induction programme should be carried out to ensure it meets the Skills for Care minimum standards. We looked at the supervision records for other members of staff. These showed regular planned supervision sessions had taken place last year. However, there were none available for 2009. The manager agreed to address this shortfall and gave her assurance an individual programme for all staff will be re-introduced. The service continues to provide regular training for staff. As well as supporting staff to achieve NVQ qualifications, the service has provided training in basic first aid and safeguarding people from abuse to ensure people’s safety and well being is promoted and protected. Information booklets have been provided to staff on the Mental Capacity Act and Deprivation of Liberties Act in preparation for seminars that have been arranged service. Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People using the service experience good quality outcomes in this area. The people who live in this home benefit from a well run service. However, for them to be fully confident their views underpin self monitoring, review and future development plans for the service, a comprehensive quality assurance system should be implemented. There are suitable procedures to ensure the health, safety and welfare living at the home is promoted and protected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 23 Lindsay Price, registered manager has the relevant experience to run the service. She periodically updates her knowledge and skills by attending relevant training. Mrs Price informed us she has been unable to complete her care management course because the company is no longer trading, but will be registering with another training company. We have received positive comments about the way the manager runs the service. People who live in the home told us “she looks after us” and “helps us if we have a problem or are worried”. Staff said she is always available to provide guidance and support. The service carries out monitoring on different aspects of the service. However, these are not linked to a quality assurance system that follows a cycle of planning-action-review that reflects its aims and outcomes for the people living at the home. The responsible individual and registered manager are aware of the need to address this and produce an annual development plan based in its findings. There are systems in place to monitor safe working practices within the home, for example records of fire drills include the names of staff who participated, the time the drills took place and how people living at the home responded. Portable electrical appliances are checked annually by a person qualified to so as is other appliances and equipment. We looked at the information kept about the environment. The records show senior staff trained in risk assessing carry out regular checks to ensure a safe environment continues to be provided for people who live and work at the home. There have been not incidents that have required a visit to the Accident & Emergency department of the local hospital. The manager is aware of her responsibility to notify the relevant agencies of any such accident or event which adversely affects the wellbeing of any person living in the home. Kiniths House DS0000071454.V374817.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 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 2 2 3 3 X 4 X 5 x 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 X 2 X X 3 X Version 5.2 Page 25 Kiniths House DS0000071454.V374817.R01.S.doc Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA1 YA6 YA6 Good Practice Recommendations The Statement of Purpose and Service User Guide should be produced in alternative formats to ensure individuals have good access to information about the service. The service should continue working with individuals in producing person-centred care plans. The policy and procedures for use of restraint should be reviewed to ensure appropriate guidance in responding to escalating behaviours is provided to staff in order to ensure people are protected from harm. Improved recording systems should be provided for medication required to be taken away from the home to ensure people’s health is protected by enabling accurate auditing to take place. Additional electrical sockets should be fitted in the two vacant rooms before they area occupied to ensure people are able to use appliances safety from a place of their choosing. A record should be kept of the service’s action taken to DS0000071454.V374817.R01.S.doc Version 5.2 Page 26 4. YA20 5. YA24 6. YA34 Kiniths House 7. YA35 8. YA39 verify references and of issues discussed with applicants during interviews to demonstrate it has followed a robust recruitment system to protect the well being of people living in the home. The service should review its in-house induction for newly appointed staff and provide them with an induction programme that meets the Skills for Care minimum standards. A record of progress and supervision sessions should be recorded for monitoring purposes. A comprehensive quality assurance should be implemented that enables the service to assess its overall performance in meeting its aims and outcomes for the people living at the home and produce an annual development plan based in its findings. Kiniths House DS0000071454.V374817.R01.S.doc Version 5.2 Page 27 Care Quality Commission West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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