Inspection on 15/12/07 for Kelvedon House

This inspection was carried out on 15th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kelvedon House 11/08/09

Kelvedon House 09/10/06

Kelvedon House 20/10/05

Kelvedon House 23/05/05

Kelvedon House 28/10/04

Kelvedon House 16/06/04

Kelvedon House 05/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Maple Lodge

Polesworth Group 32 Station Road

Heathlands

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Kelvedon House 10 Clarkson Road Wednesbury West Midlands WS10 9AY Lead Inspector Mr Jon Potts Key Unannounced Inspection 15th November 2007 09:35 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 Kelvedon House DS0000004847.V355104.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. Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kelvedon House Address 10 Clarkson Road Wednesbury West Midlands WS10 9AY 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) 0121 505 7775 F/P0121 505 7775 no e-mail www.kelvedonhouse.co.uk Mr Sarwan Samrai Mrs Shindo Kaur Samrai Vacant post Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One service user (male) in the category of OP may also be MD(E). This will remain until such time that the current service users placement is terminated. Two service users (female) in the category OP may also be DE(E). This will remain until such time that the current service users placements are terminated. One service user identified in the variation report dated 29.12.04 may be accommodated at the home in the category MD(E). This will remain until such time that the service users placement is terminated. 9th October 2006 Date of last inspection Brief Description of the Service: Kelvedon House is a Private Care Home, providing residential care and accommodation for up to eighteen frail older people. The Home is situated approximately a quarter of a mile from Wednesbury town centre, on main bus routes and close to the M6 motorway system. It is located close to easily accessible public transport routes to local areas and surrounding towns. There is limited car parking, two cars at the frontage, with some on road parking nearby. The accommodation is provided on two floors and consists of two double, and one en suite single and thirteen single bedrooms. There are two lounges and a dining area, eight toilets, three bathrooms and a shower. The home did have extensive gardens to rear of the premises, these now in use for the construction of the new build Kelvedon and as such not currently accessible to residents. There are no dedicated smoking facilities as such, though smokers at the Home may use the staff room or small greenhouse in the garden. The home does not provide intermediate care. There is the staff team of 20 people including 17 carers and the acting Manager. The level of fees for this home is currently between £335 and £350 per week (this as seen in the resident’s handbook). This home does not charge top up fees. Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over three separate visits and involved what was primarily an assessment of the homes performance against key national minimum standards. Evidence was drawn from a number of sources but including the tracking of resident’s care, which involved looking at care records, talking to residents and relatives about these and life in the home, as well as considering the views/knowledge of staff. Other evidence was drawn from reading other documentation including that related to health and safety and staffing. There was also information supplied pre inspection by the homes management (within an AQAA – annual quality assurance assessment) and from residents and relatives (the latter through CSCI questionnaires). The residents, relatives and staff and management are to be thanked for their assistance with the inspection process. What the service does well: What has improved since the last inspection? There has been much improvement since the last inspection, this measured in the following areas where the home has satisfied a number of statutory requirements: Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 6 • • • • • Whilst there is scope for some further improvement care plans were judged to be good overall and there has been improvement in respect of such as the highlighting of dietary preferences and nutritional assessment. A pharmacist has visited the home to carry out an audit of the homes systems for the administration, storage and recording of medication, and the home has responded to this so as to make their practice safer. One example of this is that staff administering medication are now appropriately trained. Staffing levels have increased during the evening period. Staff have received training in infection control and as a result have knowledge of safer practice. It is to be noted that work of the ‘new Kelvedon’ has now commenced in the grounds of the existing home. 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. Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 7 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 Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 8 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): 1,3 & 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individuals looking for a care home are given sufficient information by staff at Kelvedon to allow them to make an informed decision, this assisted by the availability of staff to talk about the home to them. Robust assessments of the individuals needs ensure that the home is aware of prospective residents’ requirements pre - admission and in a good position to ensure that these are met. EVIDENCE: Based on sight of the homes statement of purpose and service users guide the home understands the importance of having sufficient information available that can be given to prospective people who are choosing a Care Home. The way the acting manager handles visits to the home from people who are looking for a service was seen first hand and showed that information is made readily available with opportunity for individuals to discuss any queries at this Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 9 point. A trial visit was also heard to be offered so that the service provided by the home could be sampled. The home is developing methods to assist with the presentation of the home to potential users, this including the development of a website that has photos of the home, and is (stated the provider) to include a video presentation of Kelvedon house. Questionnaires received from residents and relatives indicated that 7/8 felt they had received sufficient information about the home prior to admission. The homes statement of purpose was seen to be detailed and specific to the individual home, and the resident group catered for. It clearly sets out the objectives and philosophy of the service supported by a Resident’s guide (in larger print that the aforementioned statement of purpose having some colour and pictures). The guide details what the prospective individual can expect and gives a clear account of the services provided, quality of the accommodation, qualifications and experience of staff and how to make a complaint, although does not at present contain comments and experiences of residents living at the home. The latest CSCI reports were seen to be readily available in the homes foyer area. Based on tracking the care of residents recently admitted admissions are not made to the home until a full needs assessment has been undertaken, this by a social worker where the individual is funded through care management arrangements. In discussion the acting manager was well versed in how an admission should be carried out, this in accordance with the homes procedures and national minimum standards. Comments from relatives evidenced that the home carries out admissions professionally and sensitively, involving the individual, and their family or representative, where appropriate (as was observed). One relative stated that the a staff member went through ‘everything’ prior to admission and that the home ‘deals with things in the right way’ Prospective individuals are given the opportunity to spend time in the home. An individual member of staff is allocated to give them information and to help them understand how the home is organised and run and the facilities and services available. The allocated staff member will give them special attention, help them to feel comfortable in their surroundings, and enable them to ask any questions about life in the home. Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individual needs of the residents are documented and agreed with the individual and/or their representative through consultation and generally reflect the care that the staff provide with some exceptions. The residents say that their healthcare needs are met and the home is good at promoting resident’s privacy and dignity. The home has generally satisfactory arrangements for administration of medication, which safeguards residents’ well being. EVIDENCE: The home has developed its care plans and these were seen on the whole to be comprehensive covering the majority of personal healthcare and dietary needs. There was evidence of the involvement of residents and their representatives (as appropriate) through signature and agreement to these documents. There has been evident development with key staff now sitting to Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 11 talk to residents as to the care they receive at the home this to assist with the reflection of their personal views within the care planning process, this a matter some relatives spoke of and confirmed. There was also evidence that the residents and their relatives are involved in six monthly reviews with the acting manager, these organised despite the lack of robust reviews by the placing authorities. There is scope for improvement in respect of care planning, the following illustrating pertinent gaps that were found during case tracking: • One resident was documented as having episodes of ‘restless’ behaviour where they became agitated and distressed. The home needs to ensure that there are robust behaviour plans in plan that identify what the possible triggers to this anxiety maybe and what steps staff must take to support the resident during these episodes. This approach maybe applicable to other residents that may have dementia related illnesses. • A review raised the need to ensure that one resident was involved in a toileting plan (this agreed with resident/relatives) although a month latter this detail was still not documented within their care plan. • There was a need for greater detail in one care plan in respect of the specific response needed for diabetic care, this an issue the acting manager was already aware of at the point of the inspection. On a positive note all care plans had clear detail in respect of any pertinent communication needs of residents, and the staff expressed an understanding of these. Based on documentation the home was seen to have robust individual risk assessments in place relating to nutrition, falls, continence, moving and handling. Overall these were well completed and followed through into practice although could be more robust in respect of residents who have mental health issues and potential behaviours. The acting manager was also advised to consider use of a MUST tool to clarify whether there was any response necessary based on a residents height v weight. Resident’s healthcare needs are generally well identified and in the majority of cases responses to these are timely and measured with involvement of health care professionals as and when needed. Whilst recording of contact with some services such as chiropodists, opticians and dentists could be better, there was some evidence of contact, this supported by comments from residents and relatives who felt the home was good at ensuring healthcare was provided. Staff have access to training in health care matters and are encouraged and given time for involvement in training although would benefit from a better understanding of depression in older people, and how this manifests in respect of potential behaviours. Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 12 The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Where there are errors staff know what steps to take and the management has evidenced a robust response to poor practice issues. Medication records are fully completed, contain required entries, and are signed by appropriate staff. There has been a recent audit by a pharmacist since the last inspection of the home and there was evidence that any issues raised by this have or are been addressed by the home. The only further issue of concern at the time of the inspection was that there were some prescribed creams in bedrooms not locked up, although this matter was resolved prior to the inspection’s conclusion. People who use services are given the support they need to manage their medication through risk assessment, although in the majority of cases at present the care staff manage medication either due to resident’s choice or a high degree of risk. Based on the way the home is developing care planning (with involvement of residents and their representatives within this) there is a keen interest to ensure that care becomes more individual although it is recognised by management that there is still more work to do. Discussion with staff showed that they held a good understanding of how to promote the privacy and dignity of residents and this was borne out by the majority of comments from residents and relatives who in cases gave examples of how this was put into practice. Policies and procedures supported this approach. Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 13 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 adequate This judgement has been made using available evidence including a visit to this service. There is insufficient progress of planned and spontaneous activities available on a regular basis to give residents sufficient opportunities to take advantage of and develop stimulating lifestyles. Residents are able to maintain good contact with family and friends. Dietary needs of residents are well catered for with a balanced and varied selection of food that meets residents tastes and choices. EVIDENCE: Whilst staff expressed an awareness of the need to support residents to develop their skills, including social, emotional, communication, and independent living skills comments from relatives did not reflect residents having on going daily activities that provide them with regular and appropriate stimulation. Care plans seen did not reflect that there is sufficient consultation with residents in respect of their daily activities although there was information to support that there are occasional trips out in the homes minibus, and residents were seen to be taken out on the one day of inspection (with support Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 14 from a number of relatives). It was apparent from discussion with relatives that they are in some instances very involved with the home and support the provision of activities. It still remains that outcomes in terms of activity need improvement with comments such as the following received by the CSCI: • • • • “There are not a lot of activities that go on and only just started using the minibus once a week”. “No activities only bingo I get fed up with doing nothing we could have more going on to keep our minds active, sing along exercise to music etc” “There is no stimulation, exercise going on in the home” “Some people don’t have much choice when they get old but I don’t agree with them sitting all day doing nothing bingo maybe” There was indication that staff were aware that activities were important but it was stated that residents were difficult to motivate. A lack of stimulation can reinforce dependency and consequently compound attempts staff may make to involve residents in meaningful activities. It was positive to hear from the provider that there are plans to employ a member of staff specifically for the organisation of activities, with some recognition that there is scope for improvement in this area. It was clear from discussion with relatives that they are involved in the home, with a number visiting during the course of the visit. Comments generally Indicate that the home was generally good at keeping relatives up to date despite some contention from a minority on this point. Visiting times are flexible and there are no reasonable restrictions, with staff seen to offer visitors hospitality. Care plans showed that much time has been spent exploring resident’s dietary needs and preferences, these according with the meals provided. Meals seen on the days of inspection were well presented and looked appetising with the menus (that it was stated by the cook have been recently revised with residents input) showing a good spread of meals that fitted the residents cultural expectations. There are at least two choices available at meal times, this seen to be the case from observation. Residents are asked what their choices are prior to meals been served. It was pleasing to note that the cook has responsibility for the shopping and has scope to purchase foods to reflect choices that are requested by residents. Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Complaints are listened to and action is taken to look into them, and there are systems to record investigations and outcomes. Arrangements for protecting residents are generally satisfactory. Policies, procedures, guidance and staff training are implemented in order to provide residents with safeguards from abuse. EVIDENCE: The home policies and procedures support the development of an open culture that allows residents and their supporters to express their views, and concerns in a safe and understanding environment. Residents and others involved with the service say that they are happy with most aspects of service provision, generally feel safe and well supported by the home that is aware that their protection and safety is a priority. The service has a complaints procedure that is clearly written and easy to understand and is available on display within the home. The majority of residents stated they were aware of the homes complaints procedure, as were their representatives or relatives. Most also said that staff listened to what they had to say. The home keeps a full record of complaints and this includes details of the investigation and any actions taken, although there are occasions when these Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 16 records could be more accurate. Unless there are exceptional circumstances the service always responds within the agreed timescale. The policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. Staff working at the service in discussion were aware of what constituted abuse and when incidents need external input and who to refer the incident to, or where to get the information as to who to refer it to. The home has been involved in a safeguarding referral since the time of the last inspection and whilst there was no evidence that there was any abusive practice at the home there have been some issues identified in respect of the homes practices that the service has responded to. The provider in this instance was fully co-operative with statutory agencies and attended meetings to provide information to external agencies when requested. Training of staff in the area of protection is regularly arranged by the home although there is scope for improving how the home identifies and responds to potential behavioural issues through robust care plans, this applicable to residents who have dementia or mental health issues. Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are obvious developments of a proposed new building in the grounds of the current Kelvedon. There continues to be reasonable maintenance of current home, which presents as generally pleasing and pleasant environment for residents to live in. EVIDENCE: Kelvedon provides a physical environment that generally meets the specific needs of the people who live there although the provider is aware of the shortcomings the current environment presents and building work has commenced to the front of the home on the ‘new Kelvedon’. Whilst it is accepted that there will not be major expenditure on the current building the provider was well aware of the need to maintain the current environment to an Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 18 acceptable standard and to this end spoke of having a new jet spa bath fitted, this to be relocated to the new build at the point it is commissioned. The current building does however present the residents with a homely and comfortable environment with the availability of two sitting areas and bedrooms that the residents were seen to have personalised. There was an issue with residents not key holding. Whilst this maybe their choice there does need to be a risk assessment that explores whether the resident wishes to have a key, and if so whether they are safe doing so. It is noted that the laundry and kitchen areas are well organised, clean and tidy. Appropriate infection control measures are in place and there was evidence at the time of the inspection that these were put in place for one resident where there was a suspected infection that the G.P. had advised required barrier care. Whilst staff were seen to be taking appropriate action to promote infection control the acting manager was advised that in these instances the steps staff take need to be detailed within an appropriate risk assessment within the individual residents care plan. There was some concern however that there had been occasions when the home had run out of gloves for the care staff to use and the management were advised to ensure that there was sufficient stocks to ensure this did not reoccur. The overall cleanliness of the home is satisfactory and there were no malodours at any point during the inspection. Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 19 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. A caring staff team meets resident’s basic personal care needs, with staff now available in sufficient numbers. The staff recruitment processes is robust, which results in residents receiving a consistent and generally satisfactory service. The management demonstrates a commitment to staff training and development. EVIDENCE: The home has increased the number of staff available since the time of the last inspection in accordance with the requirement placed upon the home by CSCI. Based on observations and sight of the staffing rota there are consistently enough staff available to meet the needs of the people using the service although as previously stated their deployment in respect of the provision of stimulation needs to be managed better. Ancillary staff including a cook and domestic support the care staff. Residents and their representatives generally expressed confidence in the staff that care for them and commented accordingly: • “They treat each resident as an individual and care for their particular needs” • “The staff at Kelvedon are a caring people” Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 20 • “Staff are good and the care is good” The home has a staff-training plan and this shows that the home aspires to train people beyond the basic requirements. The Management encourage and enable this and recognise the benefits of a skilled, trained workforce. It was however noted that following on from a requirement made at the last inspection the homes training/ development plan still highlights a need for staff to have moving and handling training, this identified as been provided within 4 months. As a essential area of skill/knowledge the management must ensure that all staff have access to this training, this to staff are aware of how to safely transfer/lift residents. The service has a focus on ensuring staff receive training relevant to the needs of the residents with the majority of staff having had involvement in such as dementia care training. The management do need to ensure that links from training are made between the theoretical and practical in respect of such as the following examples: • Residents with dementia have access to appropriate occupation/activity that may distract from anxiety, negative behaviours etc. • Care plans in respect of such as expressing sexuality are used to explore appropriate strategies to promote positive self-image in respect of their gender. The service has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. Staff meetings take place regularly. Supervision sessions whilst not at the regularity expected have recommenced since the acting manager has returned to the home and staff spoken to were positive about the support these sessions offered them. Staff are also provided with handbooks. Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 21 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): 31,33,34,35,36 & 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The management team is providing leadership, direction and generally good management arrangements, which should improve continuity and consistency in terms of effective leadership and support. The standard of record keeping and health and safety compliance at this home is generally good, providing protection for residents from risks of harm EVIDENCE: The home has gone through some fluctuation in terms of management this year with the registered manager having left, an acting manager having taken Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 22 up position and then leaving shortly after to be replaced by the previous manager. Based on comments from the resident’s relatives this has seemingly had the effect of (in some instances) undermining their confidence in management, possibly due to differing management styles. The previously registered manager is however working hard to redress this balance and the service is judged to be improving. The current manager is quite clear that she is not taking on the registered managers position in the long term and on this basis the provider has recruited a new manager who will take over in the new year and manage the transition to the ‘new Kelvedon’. To avoid any issues in terms of crossover between managers the existing ‘acting’ manager will remain at the home for an extended handover period, this to assist with consistency. Discussion with the new manager evidenced that she has experience of care home management and the appropriate qualifications, this to be validated at the point she applies for registration. The registered person has the skills and ability to deliver good business planning, and effective financial controls, this supported by the use of consultants who have assisted with this process. The home has utilised the annual quality assurance assessment (AQAA) to assist with their quality assurance and monitoring processes although the simplification of the homes plans (as were seen to be detailed in homes extensive and comprehensive business/financial plan) into such as an easy to digest document for residents and relatives perusal would be advisable. There was clear evidence that the views of residents have been built into the homes AQAA. It was stated that the provider is available for support, this evidenced by her presence during the course of the inspection and interest in the outcomes of the same. The provider was said and seen to be accessible to residents and their relatives. The homes policies and procedures supported safe practice in terms of the handling of resident’s valuables, with inventories of property (when checked found to be accurate) and clear records of monies kept. It was noted that there is a need to ensure that any residents or relatives depositing monies at the home are given a receipt for this so that they have evidence of their deposit. The home works to a clear health and safety policy, and discussion with staff evidenced they are fully aware of the policy and can relate theory into implications for their practice, also having a good awareness of their responsibilities in respect of how they would ensure the home is safe. The assessment of a sample of health and safety and service maintenance records examined shows that they are generally satisfactory. The manager has an effective system for auditing, analysing and evaluating accidents involving residents, with recent findings showing a decrease in accidents in the last few months. Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 23 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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 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 2 X 2 3 2 2 X 3 Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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(1) Requirement The registered person is: To develop and implement care plans to meet the needs of residents with dementia, including strategies to manage wandering and restless (anxiety related) behaviour This is a repeated requirement that was to have been met by the 1/11/06. Strategies for responding to a resident’s anxiety and cognitive discomfort need to be in place and based on good professional practice (for example the use of diversion to distract from negative behaviour). 2. OP12 16(2)(m) (n) The registered person must ensure that there is a suitable programme of regular activities for all residents (whether individual or group) that provides for their needs in regard to recreation and stimulation. DS0000004847.V355104.R01.S.doc Timescale for action 29/02/08 29/02/08 Kelvedon House Version 5.2 Page 25 3. OP30 13(4) 18(1)(c) 23(5) This is to ensure that residents do not lack stimulation and to ensure dependency is not reinforced. To ensure ALL staff employed have up to date mandatory training as follows: Moving & handling This to ensure that all staff know how to move or transfer residents safely. This is a repeated requirement (Timescale of 31/12/04 and 31/07/05 and 01/11/05 not met) 29/02/08 4. OP35 17(2) The registered person must 31/12/08 ensure that any monies received from residents or relatives for safekeeping is acknowledged by an appropriate receipt, this given to the person making the deposit. 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. Refer to Standard OP1 OP7 Good Practice Recommendations The registered persons should ensure that the collated findings from the homes stakeholder questionnaires are presented within such as the resident’s handbook. The registered persons should ensure that care plans are up to date and current to the care the resident is receiving in respect of such as the following: • Strategies agreed within reviews with residents and their representatives. • Toileting Regimes. • Diabetes care • Any temporary barrier care. DS0000004847.V355104.R01.S.doc Version 5.2 Page 26 Kelvedon House 3. OP8 4. 5. OP26 OP30 The registered person should ensure that records of residents involvement with all healthcare services are documented this to include dentists, chiropodists and opticians. The registered persons should ensure that there is always a sufficient supply of disposable gloves for staff to ensure good infection control is not compromised. The registered persons should provide staff with guidance in dealing with: • The management of behavioural issues that may arise due to underlying mental health (such as depression). • Identifying how a resident may promote positive self identify through their sexuality. • Accurate report writing. Kelvedon House DS0000004847.V355104.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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