CARE HOMES FOR OLDER PEOPLE
Kelvedon House 10 Clarkson Road Wednesbury West Midlands WS10 9AY Lead Inspector
Mrs Jean Edwards Unannounced Inspection 9th & 10th October 2006 08:30 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 Kelvedon House DS0000004847.V315158.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.V315158.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 Mr Sarwan Samrai Mrs Shindo Kaur Samrai Julie Hill Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Kelvedon House DS0000004847.V315158.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. 20/10/05 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 has extensive gardens to rear of the premises, with some areas 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 16 carers and the Registered Manager. The level of fees for this home is currently between £335 and £350 per week. This home does not charge top up fees. Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This first unannounced key inspection visit for 2006 - 7, undertaken by an inspector from the Commission for Social Care Inspection (CSCI), has taken place over two weekdays. All Key National Minimum Standards have been assessed at this visit. The range of inspection methods to obtain evidence and make judgements includes: discussions with the registered manager and staff on duty during the visits, examination of records and documents and discussions with residents, and relatives. Other information was gathered before this inspection visit from the submitted pre inspection questionnaire, reports of visits undertaken by the registered proprietor, notification of incidents, accidents and events, and an action plan submitted by the home following the unannounced inspection in October 2005. Eighteen service user surveys were sent to the home by the CSCI and an analysis of the seven survey forms returned is contained throughout this report. There are currently 17 people at the home, including two residents in hospital; one person returned to the home on the second day of this visit. During the visit the inspector has spoken to the majority of residents. Longer discussions have taken place with the residents whose care was looked at in depth. Relatives and other visitors have been asked for their views. Comments indicate that staff are friendly, helpful and welcoming. There has been a tour of the premises, including the communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and a sample of residents’ bedrooms, with their permission. What the service does well:
Residents and their families are encouraged to be actively involved in planning the way that care is provided. Full details of each person’s likes and dislikes, preferred daily routines, hobbies and interests are recorded in a care plan. The care is regularly reviewed at meetings involving the resident and their family or representatives. Residents feel they can treat Kelvedon House as their own home and to be as independent as they wish. The staff team are caring, committed and flexible, often willing to work extra shifts. There is a warm and genuine rapport between staff and residents with lots of friendly chatter. Responses from the CSCI service user survey forms indicate staff are always ready to listen and help residents, and They are very helpful at all times, and the staff are very helpful and caring. Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 6 Kelvedon House is generally clean, tidy, homely and comfortable. The tables in the dining room are attractively laid with freshly laundered tablecloths and small vases of flowers. Residents are generally able to have meals at times to suit them, and with friends if they wish. Other people have meals on trays in their own rooms. The manager has made sure that all staff have received up to date complaints awareness and training. This continues to be a topic of discussion during staff meetings. Recruitment of new staff is thorough and staff files personnel files are very well organised and easy to audit, providing evidence of robust safeguards for vulnerable residents. Good progress is being maintained to make sure that all staff are up-to-date with essential training such as health and safety, first aid and fire safety. This inspection has been conducted with full co-operation of the registered manager, staff and residents. The atmosphere through out the inspection has been relaxed and friendly. The Inspector would like to thank the proprietor, staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection?
The registered manager has reviewed the residents contracts / terms & conditions, and all but the newest resident has a received a contract. In answer to the CSCI survey questions: Have you received a contract, and in answer to: Did you receive enough information about this home before you moved in so you could decide if it was the right place for you? The majority of responses are positive with comments, I made a personal visit and we had asked the manager lots of questions, she did answer all our questions but it would been easier if more information was made more readily available. The way care is planned, provided and recorded continues to improve. The registered manager has introduced new forms to provide an index to the care plan and to provide written information for staff about each persons preferred daily routine, such a getting up, going to bed, time of bathing and so on. The registered manager has improved screening processes to identify any resident who may be at risk of falling and takes steps to minimise any known risk factors. In addition the registered manager regularly analyses all accidents to deal with any trends or additional risk factors highlighted. The registered manager acknowledges the lack of activities and states that some new activities are in the planning stage, such as a letter writing day, and film afternoons using the new TV, DVD and video recorder. The manager states
Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 7 there are also explorations of ideas for appropriate trips and outings, for example to the Walsall Illuminations. The manager has successfully recruited an experienced and skilled cook, who demonstrates she is aware of residents dietary needs, likes and dislikes. Meals are now served on different sized plates according to each residents appetite, providing larger portions for people with a good appetite and smaller portions for those people who could be overwhelmed and put off eating if served with a large meal. Additional new kitchen equipment has been provided, improving the quality of food provided. Comments from the CSCI survey forms include, On behalf of my mother I can say she enjoys her food immensely. She has a good appetite and the meals are really very good as well as a really wide choice. There are on-going improvements to the premises and equipment. Examples are the continuing programme of redecorating residents bedrooms, new TVs and new wall units in the dining room. The laundry has also been refurbished and a new commercial washer and a dryer has been installed, which improves the efficiency of the laundry service for residents and provides better protection from potential infections. The home is continuing with the programme of staff training and development and although the home does not currently meeting the required 50 of care staff with an NVQ level 2 award, all remaining staff are registered as candidates to train for the qualification. The registered manager is proactive in finding training to make sure all staff have the required mandatory and other essential training to understand and meet residents needs. What they could do better:
The organisation must not admit any new residents with conditions, which would breach the homes registration. Also an application must be submitted to the CSCI central registration team regarding two residents recently admitted with dementia in breach of the homes registration. The registered persons are reminded that the CSCI would consider any further breaches as serious. A small number of areas needing attention to provide additional safeguards for the medication system have been identified at this visit. It is acknowledged that there are plans for staff to undertake accredited medication training, however this must be completed in the agreed timescale. The manager must make sure all medication is properly booked into the home and that the pharmacy provider visits the home to audit the medication systems and offer appropriate advice and support. The home must provide an improved range of activities and social stimulation to meet residents needs and wishes. The issue of lack of activities has been raised through the responses to the CSCI service user survey forms and during the inspection visit. Comments from the survey forms are, Service user does not want to take part in the activities that are offered, Day trips and sing-aKelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 8 longs, and I sit in my chair all day nothing to do only watch TV when on. At my other home I did exercise from sitting in my chair to music very good we had music that we could sing along to very enjoyable, bingo and games but at Kelvedon we do nothing. I get very bored but I get a lot of support from my family visits. We have a bus outside on car park, we never go anywhere for a ride, and there has not been activities in Kelvedon for a while, this makes life boring. Kelvedon has a bus but it doesnt seem very mobile, nothing also been arranged for a long time. The numbers of staff on duty in the afternoons must be increased to offer adequate care, supervision and stimulation for the number of residents, some with diverse and complex needs. A previously outstanding requirement in 2002 to provide low surface temperature radiators or radiator guards and protection for exposed pipe work was deferred because of plans to rebuild the home. The registered manager sates that the registered proprietor has obtained quotations for the work to be carried out, however there is no firm date to provide radiator guards or low surface temperature radiators and protect exposed pipe work accessible to residents. This work must now be carried out in an acceptable timescale. It is acknowledged that the registered manager continues to improve the services provided by Kelvedon House. However for improvements to be continued and maintained, the registered provider should fill the vacant post of assistant manager or provides the registered manager with an appropriate administrative assistant. It is noted at this Key inspection visit that there are some areas, which are not as good as previous visits, such as activities, staffing and staff supervision sessions, which must be improved and increased. There are a small number of minor improvements needed to health & safety, such as an asbestos risk assessment of the property must be undertaken by a person or organisation competent in this area. 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. Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 9 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.V315158.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, Standard 6 is not applicable The overall outcome for this group of standards is judged to be adequate. The home has an up-to-date statement of purpose and service user guide and the majority of residents have contracts / terms and conditions of occupancy. This has the effect that residents and their advocates have information regarding their rights and entitlements, any agreed restrictions and how care will be provided. The home generally uses comprehensive assessment tools, which means that residents’ needs are thoroughly assessed to ensure that care needs will be met. The home actively encourages introductory visits and there is evidence to demonstrate that people have been given the opportunity and time to make decisions, which are right for them. EVIDENCE: Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 11 The home has a statement of purpose, which clearly sets out the aims and objectives of Kelvedon House and this is supported with a service user guide, providing good clear information about the home. Discussions with residents confirm that are given a copy of the service user guide. A notice advising people they may see recent CSCI inspection Reports and information about advocacy services are located in the reception area. The home has people from different faiths and efforts are made to ensure that staff understand the cultural expectations of those residents and there is training and guidance for staff to enable them to be responsive to the residents individual needs. There is documentary evidence in the sample of case files examined that residents are provided with a contract or statement of terms and conditions. This needs to set out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the resident. Advice has been given about the very recent revisions and additions to the Care Homes Regulation 5, which needs to be incorporated into the next review. Evidence from examination of residents records and discussions confirm that the assessment is conducted professionally and sensitively and has involved the family or representative of the resident. The registered manager uses comprehensive pre-admission assessment documentation, which is well completed. Individual preferences are recorded such as rising, retiring, preferred activities, likes and dislikes. These have not always been signed by the person or their nearest relative. However the registered manager confirms that two of the five most recently admitted residents came to the home directly from Edward Street Hospital, which provides services for older people with mental ill health. On examination of records it is clear that both residents have been diagnosed with Dementia and the registered manager is aware that their admission to the home breaches the homes registration and intends to seek a retrospective variation from the CSCI. The two residents formed a friendship in the hospital, which one persons family are keen to foster. The other person does not have any relatives. However observations over two days are that one person is demanding of the others company, which is not entirely welcomed at times. The home must monitor this situation carefully. In addition one resident is very restless at times and the behaviours appear to be disturbing to some of the existing residents. One person, also new to the home, moved from the previous care home, because of the behaviours of the people with dementia. Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The overall outcome for this group of standards is judged to be good. The care planning and monitoring provides staff with the information they need to adequately meet residents needs. There is good multi disciplinary working taking place on a regular basis, which results in the health needs of residents being generally well met. The home has generally satisfactory arrangements for administration of medication, which safeguards residents’ well-being. EVIDENCE: Each resident has a care plan, and there is evidence showing good practice of involving residents and / or their relatives or representatives in the development and review of the plan. The plan in most cases includes essential basic information necessary to plan the individuals care and includes a risk assessment element. The registered manager has introduced a proforma to record each persons preferred daily routines for staff guidance to make sure that care is delivered with a person centred approach. For example one person likes to rise at approximately at 8 a.m., has a small appetite for lunch and tea, likes to go to bed around 6:30 to 7 p.m., likes to have a bath before bed and requires the assistance of one carer.
Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 13 From examination of a sample of residents case files, some care plans have small omissions. Examples are missing areas from care plans where residents with dementia have been admitted and plans do not contain comprehensive guidance for this aspect of their care needs and associated risks. Another resident has significant weight loss, 7 lbs since April 2006, now only 5stone 1lb. This is recognised by the home and a referral made to the GP has resulted in prescribed fortified drinks. This is not currently included in the residents care plan. The home also needs to make a referral to the community dietician for support and advice to introduce additional calorific content to meals. There is evidence from records and discussions that generally each resident’s health is monitored with appropriate action taken. There is evidence in the care plans examined of health care assessments, screening, treatment and intervention. However the one of the most recently admitted 27/09/06 residents was not weighed on admission. Additionally the weight of any resident who is very underweight or has poor appetite or significant weight loss must be regularly monitored, for example weekly. All residents have good access to health care services to meet their assessed needs both within the home and in the local community. Some residents are able to choose their own GP within the limits of geographical borders and there is documentary evidence that all have access to dentists, opticians, and other community services. To overcome the difficulty for residents to be seen by NHS chiropodists, the manager has made sure that all residents are registered with the Ring and Ride Service and are taken to attend NHS chiropody clinics. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are generally recorded. However there are some omissions, where medication has not been recorded as received on MAR sheets and carried forward balances are not always recorded. There is currently one resident who wishes to administer prescribed cream, which has been risk assessed and is appropriately monitored by the home. Where medication systems are in need of action the registered person is working towards improvement. The manager needs to ensure the pharmacy provider undertakes quarterly recorded audits, with advice for the home. From discussions it is evident that staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care. However during discussions some residents and relatives say that they are not aware of their key workers name. The home arranges for residents to enjoy the privacy of their own rooms and provides screens in shared rooms, where this is the residents choice. Discussions with residents indicate that are happy with the way that the staff deliver their care and respect their dignity. Kelvedon House DS0000004847.V315158.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The overall outcome for this group of standards is judged to be adequate. There is not sufficient evidence of progress to make planned and spontaneous activities available on a regular basis to give residents improved opportunities to take advantage of and develop socially stimulating activities. The majority of 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: During discussions residents at Kelvedon House indicate that they feel they can discuss what makes them happy and can make comments where improvements can be made. The registered manager states that she takes residents feedback seriously and makes changes where possible. Evidence from the service user survey forms indicate that staff listen to residents and make considerable effort to provide a flexible service, which enables them to enjoy a better quality of life. The home has a key worker system, which enables closer resident staff relationships where likes, dislikes and needs are shared. Key workers need to
Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 15 use the information to plan activities, which residents will enjoy. There is a good understanding for the need to increase the level of activities and access to socialisation. The registered manager acknowledges that the home has experienced staffing shortages during the past few months, though the situation is now improving. The activities programme is not up to date and there have been insufficient staffing levels to allow use of the homes minibus to take residents out on trips. Comments from the CSCI service user survey forms include, I sit in my chair all day nothing to do only watch TV when on. At my other home I did exercise from sitting in my chair to music very good we had music that we could sing along to very enjoyable, bingo and games but at Kelvedon we do nothing. I get very bored but I get a lot of support from my family visits. We have a bus outside on car park, we never go anywhere for a ride, and there has not been activities in Kelvedon for a while, this makes life boring. Kelvedon has a bus but it doesnt seem very mobile, nothing also been arranged for a long time. The registered manager is making efforts to improve activities at the home, examples are that she has arranged for a personal computer to be located in a quiet area in the dining room, which will be used for a letter writing day to encourage residents to keep in touch with friends and family. The home has a new DVD and video recorder and there are plans to have film afternoons, showing films from bygone eras and sing-a-longs take place over lunch times. The manager has also obtained information about Warsaw illuminations and canal boat trips, though these have not been planned to date. Contact has also been made with a charity STAA (Sandwell Third Age Arts), which provides stimulation for older people with mental health needs through the arts. There is a written record of the visit of a representative of the charity to an individual resident, however the person does not wish to take advantage of the offer at present. The home needs to continue to develop a system for displaying information and providing access to community events and activities. There is evidence that some people prefer to spend their time on their own in their own bedrooms, with individual interests. These decisions are well understood, respected and supported by staff at the home. There is evidence that family and friends of the residents feel welcome and know they can visit the home at any time. It has been indicated that staff always make time to talk to visitors and share information with the agreement of the resident. During the visit the daughter of a newly admitted resident states, after viewing a number of homes the atmosphere at Kelvedon house with very good, and the staff of welcoming and friendly. Residents are able to have personal possessions in their room, but may be not always be able to bring large items of furniture due to for example, space restrictions or health and safety considerations. There are inventories of residents personal possessions on the sample of files examined, however these are not always signed and dated by the resident or their representative.
Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 16 There is evidence in residents case files sampled that the manager proactively facilitates each persons right to vote if they wish and it is stated that residents are enrolled on the electoral register and have a proxy or postal vote to allow them to vote in elections. Residents enjoy the flexibility of meal arrangements and are able to eat in their own room if they wish. Regular drinks are available and staff are always willing make drinks at any time. An experienced and skilled cook has recently commenced employment at the home and during discussions demonstrated that she is knowledgeable about the dietary needs of the residents. The food in the home is of good quality, well presented. Staff have received training to help those residents who need help when eating and are sensitive in their approach. The manager has introduced the use of different sized plates so that residents have portion sizes according to their preferences. People with large appetites have the large sized dinner plates and those with small appetites are not overwhelmed with large portions. During the visit the majority of residents have been complimentary about the meals provided. Kelvedon House DS0000004847.V315158.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The overall outcome for this group of standards is judged to be good. 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 have implemented in order to provide residents with safeguards from abuse. EVIDENCE: The home has complaints procedure displayed in the reception area and contained in the service user guide. Information supplied as part of the preinspection questionnaire indicates that the home has received three complaints, which have been investigated by the registered manager within the home is 28 day timescale and with satisfactory outcomes. The registered manager is continuing to raise staff awareness the homes complaints procedures as part of staff meetings. The home has not received any allegations relating to abuse of vulnerable residents. There is a copy of the Sandwell multi-agency procedures for the protection of vulnerable adults at the home. The homes policies and procedures regarding protection of residents are generally satisfactory and they have been reviewed and updated to be generally in line with regulations and other external guidance.
Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 18 There is evidence that all staff have been made aware and have been given time to read and understand procedures for the protection of vulnerable adults. The home has used the Mulberry House training pack and video to provide staff with training and awareness relating to the protection of vulnerable adults. The manager intends to continue progress is being made to provide all staff with appropriate adult protection training, which is being offered by Sandwell MBC. During the visit there has been some indication that one resident has been unhappy about the way she has been spoken to by a senior member of staff, this has been brought to the registered managers attention and following initial discussions the resident does not wish it to be regarded as the complaint or a matter of verbal abuse, rather a concern. The registered manager has agreed to conduct further investigations and deal with the matter accordingly with records of any action taken. Kelvedon House DS0000004847.V315158.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 25, 26 The overall outcome for this group of standards is judged to be good. There continues to be some uncertainty about the plans and timescale for commencement of the proposed new building. There continues to be significant and positive changes to the décor and furnishings. The incremental improvements contribute to creating a generally pleasing and pleasant environment for residents to live in. The grounds are maintained to provide a pleasant outdoor environment for residents. EVIDENCE: Discussions with the registered manager indicate that there are still no firm plans or timescale for the commencement or completion of the proposed new home on the site of Kelvedon House. The registered manager continues to improve the existing facilities for residents currently living at the home. A redecoration programme of residents bedrooms has continued with rooms attractively redecorated. An audit of residents bedrooms is in place and although not all residents have two comfortable chairs in their bedrooms, it is
Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 20 recorded that this is their decision. On-going discussions and decisions need to be reviewed and documented. During discussion residents indicate that they are comfortable, the home is clean, warm, well ventilated, and well lit. There are two spacious communal rooms and residents are able to generally sit where they wish. However there is currently discord between some residents who are disturbed by a resident frequently wanting to go into the garden for cooler air, with the open door causing draughts. An acceptable and workable solution needs to be put in place, especially before the colder winter weather. The longer outstanding requirement to provide radiator guards / low surface temperature radiators and exposed pipe work accessible to residents is being slowly progressed, with quotations sought, though there is no timescale for installation. The registered manager has devised written risk assessments, with control measures as an interim measure. It is noted that the laundry and kitchen areas are well organised, clean and tidy. Significant improvements have been made to the laundry area. The home has been provided with a new commercial washing machine with a sluice cycle and a commercial gas tumble dryer. There are clear instructions for staff relating to the gas isolation shut-off valves for the tumble dryer. Appropriate infection control measures are in place. The majority of laundry duties are still carried out by care staff. There overall cleanliness of the home is satisfactory and there are no malodours. There is a cleaning schedule are in place for the kitchen and bedrooms, bathrooms, toilets and laundry areas need to be included, with cleanliness monitored regularly. A visitor to the home during the visit drew attention to the unacceptable cleanliness of the undersides of the seats of the ground floor toilets. Kelvedon House DS0000004847.V315158.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The overall outcome for this group of standards is judged to be adequate. Staff morale is generally good, with improved diligence and less reliance on staff working in excess of contracted hours, and the staff recruitment processes are robust, which results in residents receiving a consistent and generally satisfactory service. The registered manager demonstrates a strong commitment to staff training and development. EVIDENCE: There are currently 17 residents accommodated, with a variety of dependency levels and diverse needs. Assessment of staffing rotas, observations and discussions indicate that staffing levels, especially in the afternoons are not adequate to meet all residents needs. Staffing levels must be increased to a minimum of three care staff, one of whom must be a senior carer, between the hours of 2:00pm - 8:00pm. The registered manager has agreed to review and improve the situation. It is noted that the staffing rotas do not show actual hours of shifts, even though some shifts are differing lengths, for example the twilight shift is 4:00pm - 7:00pm. There is a staff team of 20 staff, including 16 carers, 1 housekeeper, 1 cook, 1 handyman and the registered manager. Assessment of the pre-inspection questionnaire submitted, staff files and staffing rotas during the visit show that three care staff and the cook have left the homes employ since the last
Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 22 inspection visit in October 2005. Two staff are currently on long term maternity leave. Four new care staff and a cook have been appointed. The sample of staff personnel and training files for new and existing staff examined are well organised and contain all documented information required, ensuring that recruitment and retention processes are robust and appropriate inductions take place. There is evidence that 7 of the 16 care staff have achieved an NVQ level 2 care award, a ratio of 41 with the award and although all remaining care staff have registered with a training agency to undertake the award, this means that the home is not able to demonstrate that it meets the ratio of 50 of care staff (by 2005) with an NVQ 2 (or equivalent) award. The manager demonstrates a strong commitment to staff training and development and the homes training plan and individual staff training profiles are well organised. During discussions it is evident that staff are knowledgeable about what residents needs are and how to meet them and there is a warm rapport with both residents and visitors. Staff spoken to generally feel that morale is improving and that they are aware of their responsibilities, what is expected of them. Kelvedon House DS0000004847.V315158.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 The overall outcome for this group of standards is judged to be good. The registered manager is providing leadership, direction and generally good management arrangements, which should ensure continuity and consistency 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 registered manager Julie Hill has worked at Kelvedon House for four years and she has many years of managerial and practical experience caring for older people. She has achieved the NVQ level 4 care and management award, the Registered Managers Award (RMA) and is an NVQ Assessor. The manager states that she keeps up to date with new developments and practice guidance
Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 24 via the internet. She has also made enquiries about train the trainer training from the BCPC (Black Country Partnership Consortium). The home registered to achieve the Investors in People Award in 2005 but there is no date to achieve completion of the work to gain the award and there is no other accredited quality assurance system in place. The registered manager is making progress to introduce an effective quality assurance system, which includes feedback from residents and relatives, and there are plans to include stakeholders in the community. The results of the residents and relatives questionnaires circulated in June 2006 have been collated and are contained in the service user guide. The positive areas are highlighted as staff attitudes and homely environment. Staff and residents meetings also take place with minutes available. There is no current annual development plan available for the home; it is stated that the Proprietors are developing this. One of the joint proprietors make the required visits to the home and reports of monthly unannounced visits relating to the conduct of the home are made available to the home, registered proprietors and the CSCI office, Halesowen. It is recognised that it is important for the home to receive monitoring, feedback and support for its continued improvement to achieve satisfactory compliance with required standards and for the CSCI to be kept informed between inspection visits. Residents have the opportunity to manage their own money if they wish, and some facilities are provided to help keep it safe. Where the home manages money on residents’ behalf a system is in place to record transactions and accounts for spending. A sample of balances and financial records examined are satisfactory. The number of formal supervision sessions for each member of staff has decreased from the required 6 sessions each year, from a sample one person has had 2 recorded supervision sessions and another has had 3 supervision sessions. The registered manager acknowledges the difficulties for herself to achieve and maintain the very positive changes at the home without additional practical management support. The previous recommendation to recruit to the assistant managers post, a long standing vacancy or employ a skilled administrative assistant has not been actioned. This must be given serious consideration by the registered proprietors. The registered manager is advised devise an annual schedule of supervision meetings to ensure that all care staff receive a minimum of six documented supervision sessions each year. There are improvements to records keeping, which include comprehensive preadmission proformas, care plan indexes, care plans, risk assessments, daily routine proformas, and staff personnel files. Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 25 The assessment of a sample of health and safety and service maintenance records examined shows that they are generally satisfactory. There are a small number of improvements required. The Landlords Gas Safety certificate is dated August 2006, a copy of the up-to date service must be forwarded to the CSCI office, Halesowen along with evidence of an asbestos risk assessment, undertaken by a competent organisation. There have been 29 recorded accidents involving residents and 4 recorded accidents involving staff since October 2005. The manager has an effective system for auditing, analysing and evaluating accidents involving residents, with effective measures implemented. Kelvedon House DS0000004847.V315158.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 3 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 X 2 X X 3 2 2 STAFFING Standard No Score 27 2 28 2 29 4 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 3 Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 27 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 OP3 Regulation 14(1) Requirement The registered persons must ensure that no further residents are admitted in breach of the homes registration categories / conditions Timescale for action 01/11/06 2 OP4 14(1) 3 OP4 14(1) To submit a request to the CSCI 01/11/06 Central Registration Team a variation to the homes conditions of registration to continue to accommodate the two residents with dementia who have been admitted outside the registration category, as a priority To ensure that the friendship / 01/11/06 situation between the two new residents, with diagnosed dementias is monitored carefully, with evidence of on-going assessments of each persons needs To develop and implement care plans to meet the needs of residents with dementia, including strategies to manage wandering and restless behaviour
DS0000004847.V315158.R01.S.doc 4 OP7 15(1) 01/11/06 Kelvedon House Version 5.2 Page 28 5 OP8 13(1) 1) To develop care plans for any residents with significant weight loss, which includes details of fortified diet and regular weight monitoring 2) To ensure residents are weighed on admission to the home and the weight of any resident who is very underweight or has poor appetite or significant weight loss must be regularly monitored, for example weekly 3) To refer any resident significantly underweight or with significant weight loss or poor appetite to the community dietician for support and advice to introduce additional calorific content to meals 01/11/06 6 OP9 13 (2) To ensure all staff involved in the 01/12/06 administration of medication complete the planned accredited medication training 1) To request medication audits from the pharmacy provider in compliance with contractual obligations 2) To record carried forward balances of medication on MAR sheets To revise and update the current activities programme, ensuring activities and outings regularly take place and are evaluated 01/12/06 7 OP9 13(2) 8 OP12 16(2)(m) (n) 01/12/06 9 OP18 13(6) The registered manager must 01/11/06 conduct further investigations into the concerns raised about a senior carers alleged approach to a resident and deal with the matter accordingly with records of any action taken
DS0000004847.V315158.R01.S.doc Version 5.2 Page 29 Kelvedon House 10 OP25 13(4) 23(2)(p) To progress the provision of radiator guards / low surface temperature radiators and exposed pipe work accessible to residents (Timescale of 01/12/05 is Not Fully Met) 1) Staffing levels must be increased to a minimum of three care staff, one of whom must be a senior carer, between the hours of 2:00pm - 8:00pm 2) The registered manager must keep staffing levels under review and ensure there are sufficient numbers of trained, experienced, competent staff to meet the assessed needs of residents accommodated at all times 3) To ensure staffing rotas accurately reflect actual numbers of staff and lengths of shifts 4) To record ancillary duties, such as catering, laundry, cleaning undertaken on each shift by care staff 5) To record the hours and staff allocated to provide activities / social stimulation each week on rota or other format To ensure ALL staff employed have up to date mandatory training as follows; moving & handling, infection control, with documentary evidence of completion (Timescale of 31/12/04 and 31/07/05 and 01/11/05 is partly met) The registered person must forward copies the following to the CSCI office, Halesowen 1) The up to date annual 01/03/07 11 OP27 18(1)(a) 01/11/06 12 OP30 13(4) 18(1)(c) 23(5) 01/12/06 13 OP33 24 01/12/06 Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 30 development plan for the home 2) The collated results of the homes stakeholder surveys 14 OP38 13(4) The Registered Provider must ensure that an asbestos risk assessment is undertaken by a competent person or organisation (Timescale of 01/12/05 is Not Met) To forward a copy of the up-to date Landlords Gas Safety certificate to the CSCI office, Halesowen 01/12/06 15 OP38 13(4) 01/12/06 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 OP12 OP12 Good Practice Recommendations That for monitoring and evaluation that a weekly activity planner is devised and implemented for each person. That issues relating to the lack of activities and outings identified through the CSCI service user survey forms are discussed in residents meetings and reviews, with action taken for a satisfactory resolution That the registered provider gives serious consideration to filling the vacant post of assistant manager or provides the registered manager with an administrative assistant. Not Met That an annual schedule of supervision meetings is devised to ensure that all care staff receive a minimum of six documented supervision sessions each year. 3 OP27 4 OP33 Kelvedon House DS0000004847.V315158.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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