Care Home: Kite Hill Nursing Home

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What the care home does well The home has a comprehensive pre-admission procedure, which ensures that the home only admits people whose needs it can meet.All evidence indicates that the home ensures that people`s health and care needs are met. People living at the home stated the food is always/usually good with choice available. The home employs appropriate numbers of care staff that ensure that people`s needs are met. Staff receive the necessary training and good recruitment procedures are in place. The home has a very high number of care staff with an NVQ of at least level 2 in care. The provider continues to invest in the premises and equipment provided at the home. What has improved since the last inspection? Following the previous inspection in May 2006 five requirements were made. These have now all been met. Staff have received safeguarding adults training and are aware of the action they should take should they suspect that vulnerable people may have been abused. The matron is now supernumerary for two days per week enabling her to ensure that training and supervision are occurring and undertake other management functions without detracting from meeting peoples nursing needs. The providers are undertaking quality assurance work to identify areas where further improvements can be made. At the time of the previous inspection the home had almost completed an extension providing a large lounge/dining room and management offices. This has now been completed and is regularly used by people living at the home. There is ongoing improvements to the home with new enclosed ensuites being fitted into ground floor bedrooms, work on the homes kitchens and the gardens are now landscaped. New equipment has also been provided with all beds now electric profiling beds and new bedroom furniture, bedside tables and carpets provided to a number of rooms. What the care home could do better: There are no requirements made following this key inspection. Some recommendations are made within the text in the relevant section of the report. CARE HOMES FOR OLDER PEOPLE Kite Hill Nursing Home Kite Hill Wootton Bridge Isle Of Wight PO33 4LE Lead Inspector Janet Ktomi Unannounced Inspection 14th March 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kite Hill Nursing Home DS0000012562.V359371.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. Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kite Hill Nursing Home Address Kite Hill Wootton Bridge Isle Of Wight PO33 4LE 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) 01983 882874 01983 883059 mary.mclean@colvillecare.co.uk Colville Care Limited Margaret Groves Care Home 31 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (31), of places Physical disability over 65 years of age (10) Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. From time to time the service may admit service users under the age of 65 within the categories PD & DE. 27th February 2007 Date of last inspection Brief Description of the Service: Kite Hill Nursing Home is registered to provide nursing care and accommodation for up to thirty-one older people. The home is situated on the main Newport to Ryde road and can be located fractionally beyond Wootton Bridge, as you head from Wootton to Ryde. Access to the home can be achieved via public transport, the local bus company running a scheduled service that passes the home or private transportation, with car parking available to both the front and side aspects of the home. The premises is a large period property that has been extended and adapted to provide accommodation across two floors, all floors accessible via a combination of passenger lift and platform lift, ensuring all rooms are accessible to service users and visitors. The accommodation provided at Kite Hill Nursing Home is exclusively single occupancy, a large proportion of the rooms containing en-suite facilities. The home is owned by Colville Care Limited and managed by the matron, Mrs Margaret Groves. Weekly fees range between £608 to £672 dependant on assessed needs with an additional amenity charge for some rooms up to eight four pounds per week. Kite Hill Nursing Home DS0000012562.V359371.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 report contains information gained prior to and during an unannounced visit to the home undertaken on the 14th March 2008. All core standards and a number of additional standards were assessed. The visit to the home was undertaken by one inspector and lasted approximately seven hours commencing at 09.30 am and being completed at 5 p.m. The inspector was able to spend time with the registered manager (who stated she preferred the title matron) and staff on duty and was provided with free access to all areas of the home, documentation requested, visitors and people who live at the home. Prior to the visit the matron completed an Annual Quality Assurance Questionnaire (AQAA), information from which is included in this report. Comment cards were sent to the home for distribution to people who live at the home. Six comment cards were received from people who live at the home and four responses were received from professionals with regular contact with the home. Staff members were also sent comment cards. The report also considers and includes information from two random inspections undertaken in December 2006 and February 2007. Random inspections only look at specific issues and do not consider the service as a whole. Information was also gained from the link inspector and the home’s file containing notifications of incidents in the home. During the visit to the home the inspector was able to meet with and talk to people who live at the home and two visitors. What the service does well: The home has a comprehensive pre-admission procedure, which ensures that the home only admits people whose needs it can meet. Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 6 All evidence indicates that the home ensures that people’s health and care needs are met. People living at the home stated the food is always/usually good with choice available. The home employs appropriate numbers of care staff that ensure that people’s needs are met. Staff receive the necessary training and good recruitment procedures are in place. The home has a very high number of care staff with an NVQ of at least level 2 in care. The provider continues to invest in the premises and equipment provided at the home. What has improved since the last inspection? What they could do better: Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 7 There are no requirements made following this key inspection. Some recommendations are made within the text in the relevant section of the report. 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. Kite Hill Nursing Home DS0000012562.V359371.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 Kite Hill Nursing Home DS0000012562.V359371.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): 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All people are assessed prior to moving into the home to determine that their individual needs can be fully met. People, or their representatives, are able to visit the home prior to admission to assess the quality, facilities and suitability of the home. Standard 6 is not applicable, as the home does not provide intermediate care. EVIDENCE: The matron explained the homes admission procedure and two pre-admission assessments were viewed, both for people admitted shortly before the inspection visit. The inspector discussed new admissions with staff and spoke with one person admitted to the home shortly before the inspection. Comments from surveys completed by people who live at the home and professionals are also considered. Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 10 A ‘patient information book’ is provided in each bedroom containing a range of information for people living at the home and their relatives. The home maintains a referrals file that was seen to contain relevant information about people who had enquired about the home. If an initial enquiry from either social services or from a person or their family indicates that the home would be able to meet the persons needs, and they have a vacancy, the matron or a senior nurse will arrange to visit the person, either at their home or in hospital. A comprehensive pre-admission assessment is completed including where possible members of the persons family and professionals involved in their care. The home’s assessment tool covers all the relevant areas necessary for the home to decide if it is able to meet a prospective persons needs. The matron was clear about the level of care needs the home can accommodate. Discussions also indicated that the home would not admit people if they required equipment the home did not have until such equipment was available. Information in the referrals file confirmed that the home does not admit people whose needs it cannot meet. The matron explained that people are welcome to visit the home prior to admission however this is often not possible due to the level of their disability and that family members will often visit to view an available room. Discussions with people at the home confirmed that in all cases a family member had visited the home prior to admission. This was also stated in surveys completed. The inspector was able to speak with a person recently admitted to the home who confirmed the above procedure had occurred. Discussions with staff indicated that they felt they generally had enough information about new people admitted to the home. The home does not provide dedicated accommodation for short-term, intermediate care or specialised facilities for rehabilitation. However, respite care is provided, if there is a room available. There was no evidence that this arrangement had any negative impact on the existing residents. Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9,10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are set out in an individual plan of care. Medication is appropriately stored and records maintained. People are treated with respect and their dignity maintained. The home works with other agencies to ensure that people who are dying are well cared for. EVIDENCE: Four care plans were viewed one for a new person and the other’s for people who had been at the home for a longer time. The inspector discussed with staff, visitors and people who live at the home how care needs were met. A random inspection was undertaken in February 2007 following concerns being raised regarding peoples access to appropriate health care support. There was no evidence identified at that time to indicate that peoples healthcare needs were not being met with the random report stating ‘care plans and records belonging to current patients were accessible and contained evidence of instructions from GP’s and allied health care professionals having Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 12 been documented/recorded’. The random report also looked at medication following an allegation that medication was being inappropriately withheld. Again there was no evidence to support this allegation and the random report stated that ‘records indicate that medications are being appropriately accounted for when administered to clients’ and ‘that there is no historical evidence of other complaints or concerns having been raised with the Commission that supports the allegation made by a former employee’. During this inspection visit care plans viewed contained all the necessary information for staff to ensure that all aspects of health, personal and social care needs could be individually met. People have a detailed plan of care that related to the persons assessment. The care plans are person centred and written in plain language agreeable to the individual whose plan it is. Plans are reviewed on a monthly basis and people or their relatives sign their care plans. A key worker system is in place with staff undertaking a task related to their key people on the day of the inspection. People the inspector spoke with were aware of their care plans and informed the inspector where they were located. Care plans contained relevant risk assessments and management plans including nutrition, falls, and any individual risks such as resulting from age related memory loss. Within some bedrooms were records relating to food and drink people had received. Those viewed were well maintained and up to date. Comment cards from the people who live at the home stated that they always received the care and support (including medical care) they need. Comments from external professionals included ‘as far as my experience of this nursing home goes they appear to have the right skills and experience to meet health care needs’. Another comment being ‘kite hill have responded to instructions we have given them over the telephone’. Care managers stated on comment cards ‘the home gives the patient an extremely high quality of care second to none’, adding ‘from my visits I am very happy with the care and can’t see any need of improvement’. Discussions with visitors and residents during the inspectors visit indicated that they felt their health and care needs were met and that staff always treated them with dignity and respect. Observations of staff interactions and all comment cards received confirmed that people are treated with respect and their right to dignity maintained. Comment cards and discussions with residents confirmed that staff listen and act on what they say. The home provides only single bedrooms. Care staff confirmed that they had sufficient time to meet people’s needs and discussions indicated that they had a good understanding of individual peoples needs and how these should be met. Staff stated that they have a handover before each shift and are therefore always updated re anything that has changed or needs particular attention. Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 13 At the time of the inspection visit nobody was self-medicating. Each bedroom has a secure storage facility within which that person’s medication (other than controlled medication or that which should be kept in a fridge) is stored. Medication is only administered by a qualified nurse who was observed doing part of the morning medication round. Records relating to medication received into the home, administered and returned were viewed and had been maintained to a good standard. Whilst viewing the medication administration records it was noted that on the morning of the inspection visit the night nurse had not signed to confirm that a person’s insulin had been administered. This was brought to the attention of the nurse on duty who immediately contacted the night nurse who confirmed that it had been administered. Comments from people stated that they felt their medication was appropriately managed, one stating to the inspector that he had a complex medication regime that the home always gave him the correct medication at the right time. In a comment card another person stated ‘always give me my painkillers when requested’. Shortly before this inspection visit a medication error was reported by the home. The home has taken the necessary action and the nurse responsible is undergoing a period of supervised retraining. As a care home with nursing the home undertakes to provide care for people at the end of their lives. Discussions with the matron and staff indicated that they had the necessary skills and equipment to meet needs at this time of peoples lives. The home has close links with the island hospice and a comment card from the hospice stated ‘the home currently accepts support from Hospice at Home staff when experiencing difficulties with the management of end of life patients, and are keen to improve skills in this area’. Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines for daily living and activities made available are flexible and varied to suit people’s individual needs. Family and friends are able to visit. People receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: The routines for daily living and activities made available are flexible and varied to suit people’s individual needs. People confirmed to the inspector that they are able to choose where in the home they spend their day, some were seen to spend time in the homes lounge with others remaining in their bedrooms. People confirmed to the inspector that they are given choice over their meals with options being chosen on a daily basis. Bedrooms seen contained personal items brought into the home. Care plans and assessments include information Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 15 about leisure activities, hobbies/interests, catering and religious needs. People stated that they are able to get up and go to bed at times of their choosing. An activities list was noted on display in the entrance hall. This listed activities planned and provided by the activities coordinator. Since the previous inspection the home has employed specific activities staff with something provided every day including weekends when a second activities person undertakes one-to-one activities and some outings. The inspector was shown the activities book which recorded what activities had been undertaken and by whom. Information about activities was also included in individual care plans and daily records. Comments in surveys confirmed re activities included ‘I like to join sing-a-longs, like conversation, listening to stories, like quizzes, tried knitting’, another saying ‘I like to join in almost all activities and mixing with others’. People can choose to join in activities with one stating ‘I prefer to stay in my room’. During the inspection visit people were seen undertaking a craft activity in the lounge/dining room. The home has a large lounge/dining room, with pleasant views to the garden and surrounding countryside and estuary. People stated that the food is always/usually good and choice provided. Additional comments including ‘not much appetite but food is nice’, ‘lovely meals lots of choice’, ‘I have not got much appetite at present, I enjoy milkshakes, they make them with ice cream’. Another stated ‘I enjoy the food, there is always plenty. I love the ham salad at suppertime’. Equipment to promote independence was available and seen in use. Drinks and snacks are also available throughout the day with people confirming this as well as the inspector observing people being given morning and afternoon hot drinks and cakes. The need for special diets or supplements is recorded pre-admission and one person confirmed that he is provided with supplement drinks he requires. Care plans included peoples food likes and dislikes and supper and late night snacks are provided should people want this. Individual fridges have been provided in some bedrooms as part of the upgrading of facilities. The home has a large, well-equipped kitchen and has been awarded five stars (the maximum available) by the local environmental health department for food hygiene. The inspector met the cook and she showed the inspector new food information forms that key workers are completing for people living at the home. The cook stated that fresh fruit and vegetables are delivered most days and supplies were seen during the visit including fresh vegetables from which soup was being made. During the afternoon care staff were seen completing more food information sheets for the people they are key workers for. A number of people require support with their meals. Care staff confirmed that meals are always hot when they take them to people even if they are the last to be assisted. Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 16 Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. People are protected from abuse. EVIDENCE: The home has a clear complaints policy and procedure and is included in the patient information book kept in each bedroom and also in the statement of purpose available in the hallway. Comment cards returned from people who live at the home and their relatives indicated that they were aware of how to complain, adding ‘have no reason to complain’. Discussions with staff confirmed they were aware of what to do if a person complained or raised an issue. The manager identified in the homes AQAA that the home had not received any complaints in the past year. Discussions with people who live at the home during the inspectors visit and comment cards indicated that people feel able to make their views and opinions known and are not afraid to raise issues with the homes staff or management. No concerns were raised by any professionals in their comment cards. The home has a policy and procedure relating to safeguarding adults and ensuring that people are not at risk of abuse. Following the previous inspection in May 2006 the home was required to ensure that all staff undertake Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 18 safeguarding adults training and are aware of what to do should they have any concerns that a vulnerable person was being abused. The random inspection undertaken in February 2007 found that staff had undertaken in house adult protection training in January 2007 and that applications had been sent for staff to attend external safeguarding adults training being organised by the local authority. Care staff informed the inspector that they had attended safeguarding adults training provided by the local authority. Care staff were clear about the actions they should take if they suspected that abuse may have occurred. Training records and certificates seen in staff training folders confirmed that staff have undertaken safeguarding adults training. Care staff have undertaken training in Dementia and the matron informed the inspector that training about the Mental Capacity Act is planned for the future. The homes policies and procedures in respect of recruitment and people’s personal finances should ensure that unsuitable people are not employed at the home and that people will not be financially abused. Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, safe, well-maintained home that meets their individual and collective needs. The provider continues to make improvements to the home and equipment available. EVIDENCE: The inspector had visited the home before so was familiar with the layout, she was therefore able to view the home independently. The maintenance person showed the inspector rooms he was working on and described other plans for the future. The premises consists of an older building with an extension providing additional bedrooms to the rear of the home and a more recent extension Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 20 providing a large lounge/dining room. The gardens have been landscaped and car parking is available to the front and side of the home. All bedrooms are for single occupancy many with ensuite facilities. The ensuite facilities within the extension are being updated and upgraded some having walk in shower facilities in addition to washbasin and WC others having WC and wash basin. All bedrooms are equipped with modern electric height and positioning adjustable beds that have a wood effect finish, so reducing the clinical appearance. Bedrooms seen contained individual items belonging to their occupant. People stated they were happy with their rooms. Comments including ‘very pleased with my room’, ‘its lovely’, ‘I like my room, I like the bird table, I have lots of my own things and like to watch the television’. The home has a shaft and platform lift making all areas of the home accessible to people with limited mobility. The home has a range of moving and handling equipment located conveniently around the home. The matron stated that many new bedside tables have been purchased and flat screen tv’s are now provided in bedrooms. There are plans to provide an additional assisted bathroom in place of the little used first floor beverage room. The home employs a maintenance person who the inspector met. The maintenance person also undertakes all the fire equipment checks and staff fire training. Whilst viewing the home the inspector noted that the smoke strip on one person’s door was missing. This was pointed out to the maintenance person who immediately commenced replacing this. The home was found to be clean, tidy and free from offensive odours. Cleaning staff are employed. Staff stated that they have access to protective clothing and equipment and arrangements for the control of infection are in place. Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs appropriate numbers of staff that ensure that people’s needs are met. Staff receive the necessary training and good recruitment procedures are in place. The home has a high number of care staff with at least an NVQ level 2 in care. EVIDENCE: All comment cards, from people who live at the home, visitors and professionals were positive about care staff. A person who lives at the home stated in a comment card ‘I am very happy and very well looked after’, ‘friendly caring staff at all times’, ‘everyone is very kind’, ‘everyone is very nice’ and ‘staff always attend my needs’. Professionals stated that staff appear to have the necessary skills and experience to meet peoples needs. Duty rotas were seen during the visit to the home. Duty rotas stated that one qualified and six care staff are provided in the morning; one qualified and four care in the afternoon/evening and one qualified and two care at night. Cleaners, activities, administration maintenance and kitchen staff are also employed. During the inspectors visit staff on duty corresponded to those on the duty rota. Care staff stated that they generally have sufficient time to meet Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 22 people’s needs and throughout the inspection care staff appeared to have time to meet people’s needs. The matron provided training and qualification information during the inspection and on the AQAA. The home has a high number of care staff with at least NVQ level 2 in care. With eleven of the fifteen staff having a qualification. Of the remaining four care staff, two have overseas nursing qualifications and two are newly recruited and just completing their skills for care induction. The matron stated that these staff would be commencing their NVQ once this could be arranged. Following the previous inspection the home was required to supply a training programme showing how all mandatory and service specific training is provided for all staff. The random inspection undertaken in February 2007 identified that the matron had produced individual training folders for staff. The new system seen ‘possessed both a training matrix and a training record component, the latter split into two sections, the first encouraging the staff member to record and reflect on the training completed and the second for the manager to track the courses’. During this inspection the individual training files were viewed and found to contain evidence of training undertaken and include reflective practise of what people had learnt. The matron showed the inspector the new training room that is to be available to staff stating that it will contain training information and computers to enable staff to access on line courses and updates. Nursing and care staff stated that they felt they had the necessary skills to meet people’s needs and were not expected to undertake activities for which they had not been trained. The recruitment records for the three people recruited since the previous inspection was viewed. These contained all the required information and confirmed that all staff are fully checked including references, CRB and POVA checks prior to commencing employment at the home. The homes recruitment procedures should ensure that unsuitable people are not employed at the home. The matron explained the homes induction procedure that includes the Skills for Care induction. Induction workbooks were seen along with certificates for courses staff had attended. Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The matron has the necessary skills and experience to ensure that the home is appropriately managed and run in the best interests of the people who live there. People’s financial interests are safeguarded. Staff are supervised. The health, safety and welfare of people and staff are promoted. EVIDENCE: The matron has been the registered manager of the home for over five years and is a registered general nurse, has the Registered Managers Award and is an NVQ assessor with the D32 and D33 qualifications. Since the previous inspection the matron now has two days per week as supernumerary to enable Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 24 her to undertake management and training tasks. The manager also confirmed that she has undertaken all mandatory and specific training relevant to the needs of the people who live at the home. Throughout the inspection visit the matron demonstrate knowledge of the people who live at the home and the mechanisms by which support can be obtained when necessary. The providers are in frequent contact with the home with the responsible individual being present at the home at the start of the unannounced inspection visit. Within comment cards and during discussions, people who live at the home, visitors and staff stated that they felt they could approach the manager and that the home was effectively managed. The manager completed the AQAA to a reasonable standard providing relevant information about the service and returned this to the commission within the required timescales. The providers undertake a range of quality assurance activity. The Matron showed the inspector specific work undertaken in connection with admissions to the home where the providers had reviewed the admission paperwork and preparation of the home for new admissions. The matron stated that questionnaires are provided to people who live at the home and their relatives and that once completed the providers complete a report identifying any areas that require further improvement. At present other stakeholders (staff or external professionals) are not consulted as part of quality assurance work and this is recommended for the future. The home does not does not act as appointee or hold valuables for people living at the home. People’s personal finances are dealt with by the resident themselves or their families or solicitors. Should people require services that are not covered by the fees, for example hairdressing, chiropody or items from the trolley shop these are invoiced to the representative responsible for the persons money. An example of an extras invoice was seen during the inspection visit and clearly identifies what additional charges are for. The only outstanding requirement following the previous key inspection undertaken in May 2006 and the random inspections was in relation to staff supervision. Staff confirmed that they felt appropriately supervised. All staff have formal recorded supervision and written records of supervision were seen during the inspection visit. This requirement has therefore been met. Various records were viewed during the inspectors visit. All records were appropriately stored with access only available to people who should have access. Records were seen to be well maintained. During the inspectors visit there were no concerns in respect of health and safety identified. The home is generally well maintained and clean, with staff having relevant training to meet people’s needs. The home undertakes weekly Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 25 checks of the fire detection equipment and the records for these were seen. The home has its own maintenance person who is able to respond immediately to minor repairs. Kite Hill Nursing Home DS0000012562.V359371.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 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 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 27 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. Refer to Standard Good Practice Recommendations Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Kite Hill Nursing Home DS0000012562.V359371.R01.S.doc Version 5.2 Page 29 - 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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