Inspection on 10/02/09 for Kelvin Grove

This inspection was carried out on 10th February 2009.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kelvin Grove 07/03/07

Kelvin Grove 20/02/06

Kelvin Grove 30/08/05

Kelvin Grove 11/01/05

Kelvin Grove 03/08/04

Kelvin Grove 18/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOME ADULTS 18-65 Kelvin Grove 18 Rothsay Road Bedford Bedfordshire MK40 3PN Lead Inspector Andrea James Unannounced Inspection 10th February 2009 10:00 Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 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 Kelvin Grove DS0000015007.V374149.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 Adults 18-65. 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. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kelvin Grove Address 18 Rothsay Road Bedford Bedfordshire MK40 3PN 01234 217287 01234 217287 kelvingrove@together-uk.org www.together-uk.org Together Working for Wellbeing NBHA Chilterns Joanne Forrest Care Home 12 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) Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2007 Brief Description of the Service: Kelvin Grove is a large detached property on a road leading down to the river within walking distance of Bedford town centre and a range of local amenities. The home is managed by Working Together for Well-being and New Leaf Housing Association is responsible for the building. The home provides residential care for 12 people with mental health needs. All the bedrooms are single and meet the space requirement. There are communal lounge, dining, kitchen and laundry areas on the ground floor. The home has a good-sized rear garden and limited parking at the front. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection carried out on the 9th of February 2009. The inspection visit lasted for 7 hours and the registered manager was present for the duration. The inspector followed the case tracking methodology where a sample of people were randomly selected to speak to. These peoples files were inspected and where possible their key workers and relatives were spoken to. The report consists of information gathered from people who use the service, care staff, relatives and recorded information inspected on the day of the site visit. What the service does well: This service provides care to 12 people with mental health needs. The care is provided on a 24-hour basis by a dedicated staff team. People who use the service said, this place is lovely they couldnt do any better for me another person said, staff treat me well, all the staff are kind. One person who has been living in the home for 10 years said its okay here, the staff will sit and talk to me. One relative who visited the home on a regular basis said, the staff are good I am happy with the way things are. The home is clean and tidy and the staff are professional they always make me feel welcome and there is plenty of food to eat. The service provides care to people in a proactive manner and there was evidence to suggest the management team are always looking for new and inventive ways in which to meet peoples needs. One example of this was that two people who use the service were enabled to move into more independent accommodation in recent months. The service also empowers people to maximise their independence, one person spoken to said she was able to visit the community on a regular basis where she embarked on art and craft courses, music and weight training. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 6 The staff appeared dedicated and acted professionally in all areas of service delivery. One staff spoken to said, I love this place, its an enjoyable group of people, I like the client group and we work as a team here. Another staff said, We give the clients all the comfort and support necessary to maximise their independence and achieve their goals. What has improved since the last inspection? What they could do better: The home should ensure that people who use the service are protected from other peoples threats and behaviours through the implementation of effective management and safeguarding procedures. The procedures for the administration, recording and auditing of controlled drugs should be reviewed to ensure people are safeguarded at all times. The home should also review their smoking policy to ensure people are safeguarded from potential risk of fires being started in the home. Arrangements should be made to ensure all radiators are covered in an attempt to protect people from being burnt. The level of risk should be identified in all risk assessments and clearly evidenced in the paper work on peoples files. The hot water temperatures in identified areas of the home should be regulated to prevent potential harm to people who use the facilities provided. Effective staff training and development plans should be in place to ensure care staff have the skills and competencies required to meet peoples needs. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 7 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. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, 3 &5. People who use this service experience a good quality outcome in this area. We have made this judgment using a range of evidence to include a visit to the service. People who use the service were given sufficient information and their needs were assessed prior to admission to the home. EVIDENCE: The home had a Statement of Purpose and Service User Guide which was made available to people who use the service. We were informed that the Statement of Purpose was reviewed three weeks ago in the residents’ meeting but the document itself had not been updated to reflect the changes. The minutes of the residents’ meeting seen confirmed this information. The Statement of Purpose was last updated on the 5th of September 2007. People spoken to said they were given a copy of the Service User guide. The document provided information about the bedrooms, activities, responsibility of residents, medication, transport, equal opportunities, financial arrangements etc. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 10 A sample of peoples records inspected suggested people were subjected to a full comprehensive assessment of need prior to admission and further assessments were undertaken upon admission to the home. One persons needs assessment seen suggested the home had used a Person Centred Approach, which was signed and dated by the person whose assessment was undertaken. This was also complimented with a needs assessment undertaken to reflect the professional needs of the person. Areas such as goals, limitations, mental state, short-term goals were identified and explored. The home had also ensured that people had contractual agreements to reflect their care needs as well as their accommodation. These documents were signed and dated by the appropriate people and kept on file. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. People are consulted about their care needs and the support plans and risk assessments showed where consistency of care can be maintained. However further development was needed to ensure the level of risk to people is identified and clearly recorded on peoples files. EVIDENCE: We inspected 4 of the peoples care plans in detail. We were told that a new care planning procedure was being implemented and one of the 4 peoples care plans had already reflected the new care planning procedure. In the new procedure one persons plan showed that a daily planner was implemented showing personal care needs, medication contract, needs assessment, social/ psychiatric history, risk assessment for challenging behaviour, management plans and relapse indicators. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 12 There was also a CPA care plan and needs assessment and a summary of individual needs. The support plan itself covered areas such as accommodation needs, personal support, physical and mental needs, culture/faith, specific conditions relating to needs and specialist input. There was also specific information about how to meet the goals and objectives identified. The information was recorded in a clear and simplified way for staff to understand. It is hoped that all the care plans will be reflective of this standard. The risk assessments seen suggested people were supported to take risks as part of their independent development, however these risk assessments failed to identify the level of risk posed to themselves and others. For example one person who repeatedly threatened to bring harm to staff and other people who use the service had in place a risk assessment but it was not clear what severity of risk people could be open to. The care plan documentation for other people seen were not as detailed, and in some cases were not available on file. The manager said they were in the process of updating all the care plan documentation. Staff spoken to appeared knowledgeable about the needs of people and how to meet their mental health needs. The relapse indicators for some people were very clear and staff would be able to know if a persons mental state had deteriorated. People spoken to said they were able to make decisions about their lives and spoke openly about how they manage to do this. One person said she helped with the cooking and cleaning of the house while others commented that they were able to access community resources and undertake activities such as pottery art and craft and music. Since the last inspection two people have been able to move into more independent living accommodations. On the day of the inspection one of the people who recently moved out came to visit. He said the staff are very supportive and had empowered him to be able to make decisions about his life. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 16 & 17. People who use the service experienced an adequate quality outcome in this area. We have made this judgment using a range of evidence to include a visit to the service. People who use this service have opportunities for personal and social development, but further development is needed to ensure people receive sufficient leisure and structured activities that will enable them to live fulfilled lives. EVIDENCE: People who the service were given various opportunities for personal development. The staff team showed great enthusiasm in the way they empowered people to develop wherever possible. We were informed by the staff team that people are encouraged to access colleges, day centres and leisure facilities within the community. One person works voluntarily once a week for a local community resource and people received one-to-one activities such as cooking and gardening, although this was stopped recently due to lack of interest. People are also encouraged to clean their rooms and undertake their laundry independently. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 14 However on the day of the inspection there were limited opportunities for activities. We observed several people throughout the day sat watching television or just sitting around in communal areas or bedrooms. One person was taken to see the GP on the day of the inspection but no other structured activities were observed. The manager commented that it was sometimes difficult to stimulate and motivate the client group due to their mental health. People spoken to said they were happy with the level of activities. One person said I dont do a lot, I only clean my room. Another said, I help to clean the lounge. Staff spoken to said, people appear happy to do what they want at their own pace, but we try our best. Two staff said, We need more money into the project to be able to go on trips with people. The home manager said people are encouraged to undertake activities but their was no recorded evidence of this in the home. Relatives are able to visit the home whenever they so wish. One relative spoken to said The staff are good, and they make me feel welcome. One person said her sisters’ visited her on a regular basis. Records seen suggested relatives were consulted about the care to be implemented to individual users of the service. People spoken to said their rights were respected. One person was seen smoking in her room and the manager explained that it was against the homes policy and explained the implications to this person at the time. This person was able to understand and took responsibility for her actions. Another person was seen undertaking the laundering of his clothes independently and followed the procedures implemented in the home. The home was able to meet the peoples dietary needs and provided a healthy balance. We observed a breakfast and a dinner menu which showed choices were offered and variety was available. For example on one morning people were offered a number of cereals, on another cooked breakfast was provided and people were able to say in advance what they would like to eat on any one day. Relatives commented that the food was good. One relative explained that they were also invited for a Christmas meal which was very tasty. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. People received emotional and personal support in a satisfactory way but further development was needed to ensure the policies and procedures in place for the safe administration of controlled drugs is reviewed, as a result some people could be placed at risk. EVIDENCE: Staff spoken to were knowledgeable about the needs of people who use the service and the support they required. The mental health needs of people were reviewed on a regular basis both in house and by external professionals. We saw evidence to suggest people received monthly reviews from their key workers and external professional meetings were held annually. The manager also informed us that when needed she had the support of social workers and outreach team who helped to implement satisfactory management procedures for dealing with people who can challenge the service. We were informed of one person whose behaviour appeared to have challenged the service in regards to his threats to kill both staff and people who use the service and another person who refused to take her medication. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 16 We were concerned that the management procedures in place may not be satisfactory to safeguard people and the risk assessment also failed to identify the level of risk. As a result of this the home was issued with an immediate requirement to ensure safeguarding procedures are implemented. The home made a safeguarding referral to the local authority and as a result effective management strategies have now been implemented by all concerned. Some people who use the service are sectioned under section 3 of the Mental Health Act and as a result the home have close liaison with the crisis team who visit the home whenever required. The home showed that in general they were able to manage the changing needs of some people in a proactive way. The manager said she was keen to increase the involvement/response from the Crisis team when an individuals mental well being became poor. The home had satisfactory procedures in place for administering medication on a daily basis and the medication for people were satisfactorily maintained in regards to administration and recording. However further development was needed to be made in regards to the safe administration, and recording of controlled drugs. The controlled drugs for one person showed that 12 tablets were unaccounted for. When we asked about this we were informed that the home had recently changed pharmacists and they could not account for the missing tablets. It was difficult for us to audit the information because the home did not have a controlled drug book. The manager implemented a hard back book before the end of the inspection and said they would use that book to record controlled drugs in the future. The home also needed to ensure two staff signed for the administration of controlled drugs. The home had satisfactory procedures in place to store medication safely and staff spoken to said they received medication training and felt competent to administer medication. Some people who use the service were enabled to self medicate and this was monitored on a regular basis by the staff team. We were informed that an audit of all medication was undertaken on a weekly basis. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23. People who use this service experience a adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. There were satisfactory systems in place to ensure peoples concerns could be dealt with, but further development was needed to ensure people are protected from harm, as a result some people could be at risk. EVIDENCE: The service provided sufficient information to enable people to be able to make a complaint should they wish to do so. The home had a record of complaints received and responded to complainants in accordance to their policies and procedures. The home failed to show evidence that they were aware of the safeguarding procedures in place to protect people. The training records failed to show that staff had any understanding of what to do in the event people were being abused. The manager said she had received the training and had passed this onto the staff team but their was no recorded evidence to confirm this. The home had no safeguarding or alert procedures in place. There was evidence to suggest one person was subjected to harm by the radiator that was situated beside her bed. She explained that the radiator gets very hot and on one occasion she burnt her leg. She said she has to turn it off when she is in bed and as a result gets very cold because her window was also broken and the room gets very cold. This person was not at any immediate Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 18 risk as she was physically able to take herself away from the radiator but the home failed to make suitable adjustments. Since the inspection we were told that radiator covers were provided for this bedroom and actions were taken to repair the window. People who use the service were protected from financial abuse. Records inspected suggested a satisfactory procedure was in place for the safe storage and recording of peoples finances. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,28 &30. People who use the service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. The home presented a warm and welcoming environment where people appeared comfortable and happy to be, however further development was needed to ensure peoples safety is not compromised by the environmental standards. EVIDENCE: The service was warm and provided a comfortable and welcoming environment for people who use the service and visitors. In general most of the home was clean and adequately decorated but some areas of the homes carpets and toilet floors were in need of cleaning. The kitchen appeared clean but the cupboards were broken and the paint work had started to strip away making the kitchen to become unwelcoming and detracted from the rest of the homes presentation. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 20 Some peoples bedrooms were of a satisfactory standard but again some appeared very worn and tired and in rooms where people were heavy smokers their bedroom ceilings were discoloured. One person who complained that she was burnt by her uncovered radiator also explained that her window had been broken for two weeks and had not been fixed, the window was not double glazed and as the person said Its very drafty. It was also noted that none of the windows throughout the home were double glazed. The manager said the people providing the accommodation have been informed that something needs to be done but appears to be taking their time. We observed that none of the radiators in the home had been covered. Since the inspection we have received information to suggest people are now safeguarded. It was concerning that some people were smoking in their bedroom. The home had clearly informed people not to do so but they had ignored this request. One persons bedroom we visited was so thick with smoke that the atmosphere was cloudy and it was difficult to breathe. The smell of cigarette smoke permeated the rest of the building which would be unpleasant for non smoking people who use the service. It was suggested that one area is identified as a smoking area if people are insisting that they will smoke. This could then be monitored and would reduce the risk of fires. Some areas of the home namely the kitchen and laundry room had hot water being distilled from hot water taps with temperatures of over 50 degrees. The manager said as a rule they turn the water off in the kitchen and it is only used with supervision from the staff team. The home had a large lounge and a separate dining room, separate laundry room and a conservatory that enabled all 12 people who use the service to have sufficient space to be able to live comfortably. The home was clean and hygienic but the offensive odour of cigarette smoke was evident in several areas of the home. One person spoken to said its ok as a shelter, Relatives spoken to said, I am happy with the way things are. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, &36. People who use this service experience an adequate quality outcome. We have made this judgment using a range of evidence to include a visit to the service. People who use the service benefit from a competent and skilled staff that provides effective service delivery however further development was needed to ensure effective recruitment and training records are maintained and kept up to date. EVIDENCE: The home has one full time manager, 1 deputy manager, 2 senior carers and 6 care staff. The staff works on a shift basis where 2 carers work from 8 am to 3; 30pm and another 2 from 1:30pm to 10pm. 1 staff works at night as a sleep in. It was suggested that the possibility of a wake in staff should be considered to ensure peoples safety. We spoke to 4 staff members who were all very complimentary about the home. Those spoken to were very clear about their roles and responsibilities. Staff spoken to said, I am happy with the home we try and do our best. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 22 The communication among the staff team and the way in which they worked was very commendable. One staff said we have excellent communication among ourselves as a team. Another staff said, We work as a team. While another said ,we provide a comfortable and supportive place for people to be able to achieve their goals. Some staff spoken to said the home had good recruitment procedures. One staff member said she was very impressed with her interview because 2 of the people who live in the home were on the interview panel. It was concerning however that the records for staff were not available for inspection on the day as the manager said she was in the process of redesigning the filing system. We were able to see the file for the deputy manager which had interview notes, references, passport information, contract and declaration of fitness to work, however we failed to see an application form and the Criminal Record Bureau check was dated 2003 which would suggest another would need to be undertaken. No other files could be inspected on the day. The staff spoken to said they had received some training in 2008. These included Mental Health, cognitive behaviour therapy, food hygiene, health and safety and goal planning. We were informed that of the 6 care staff 1 has an NVQ level 3 qualification and a further 3 staff have recently embarked on the qualification. Staff spoken to were able to confirm this information. We were not able to see recorded evidence that other training has been undertaken. This was because the staff files were not available and the home failed to have a training development file for the staff team. We saw some staff certificates but these were mostly outdated or and was for staff no longer working in the home. The home have not identified any areas for training in 2009 but said this was carried out corporately by the organisations head office. The manager said she was waiting for the new training programme for 2009-10 which was due to be in place in the near future. Since the inspection we received information about future training needs identified for the staff team at the service. 2 care staff, I senior worker began their award in September 2008 and are due to complete in June 2009. It was concerning that we could not prove if staff had had recent training in safeguarding or medication since the last inspection. The manager said she gave an in- house training to staff on safeguarding but this could not be evidenced. All staff said they received regular support and supervision. There was some evidence to suggest staff had regular supervision. Staff spoken to said, the manager has a good heart, she feels for anyone and she understands you. We observed a very relaxed but professional relationship between the manager and the staff team. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,42 &43. People who use this service experience an adequate quality outcome in this area. We have made this judgement using a range of evidence to include a visit to the service. People who use the service benefited from a positive leadership approach to the home but further development was needed to ensure peoples best interest and welfare are safeguarded, as a result some people safety could be compromised. EVIDENCE: The manager of the service has worked in the home for 4 years and has recently been registered with the Commission. She has a good understanding of the needs of the people and implemented several systems that given time will prove productive to the development of the service. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 24 The leadership of the home in regards to the management of the staff was of a good standard and staff moral was high. Staff commented that the manager was very understanding of their needs and she would always find time to communicate with them. One staff said she has a good heart. People who use the service also felt able to communicate their needs to the manager. The accountability of the manager was compromised when for some people their safety and welfare was not protected. See the environmental and personal and health care support sections of this report. The home had various health and safety policies and procedures in place. We saw evidence to suggest fridge / freezer temperatures were undertaken, 6 monthly deep cleaning of rooms, monthly checks for sockets and hot water. We were also informed that a water company visits the home on a regular basis to check water in bedrooms which were being maintained. Their records showed that water from laundry room was over 60 degrees. Fire checks were also undertaken in regards to alarms, extinguishers, emergency lighting, evacuations and drills. These were recorded and kept up to date. Records seen suggested risk assessment for fire was undertaken in 2007 and was updated on a 6 monthly basis. Fire wardens came to see the home in February 2009. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 2 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 2 13 3 14 1 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 x 3 3 X X X 2 2 Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (1) Requirement Timescale for action 30/04/09 2. YA9 13 (4) (c) 3 4 YA14 YA20 12 13 (2) Arrangements must be made to ensure all care plans are up to date and reflect the current needs of people who use the service. All risk assessments must be 30/04/09 reviewed to ensure the level of risk can be identified. In doing so you will be able to ensure clear risk management strategies are in place. People must be encouraged to 30/04/09 pursue appropriate activities. The policies and procedures for 10/02/09 the safe administration and recording of controlled drugs must be implemented. 5 YA23 An immediate requirement was issued on the day of the site visit for this to be achieved. 13 (4) (c ) Arrangements must be made to ensure people are safeguarded from potential abuse or loss of life that could be caused by other users of the service. An immediate requirement was issued on the day for this to be done. 10/02/09 Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 27 6 YA23 13 (4) 7 YA24 23 8 YA33 18 9 YA35 18 10 YA35 18 (i) 11. YA42 23 Actions must be taken to ensure people are safeguarded from burns and scalds from uncovered radiators or hot water. Arrangements must be made to ensure the home is well maintained and decorated in all areas. This includes the kitchen and windows. (10 (a) Satisfactory arrangements must be undertaken to ensure sufficient numbers of staff are employed in the home at nights. (1) (a) The registered provider must ensure that an up to date staff training and development plan is in place that accurately reflects the training needs of the staff team. (1) (c ) All staff must be trained in Safeguarding and medication training to ensure they are able to meet the needs of people who use the service. The registered person must make arrangements for safeguarding people from potential fires that may be caused from people smoking in their bedrooms. The registered provider must ensure the home has effective structures in place to protect people at all times. 30/03/09 30/05/09 30/04/09 30/04/09 30/04/09 30/04/09 12 YA43 10 30/04/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA12 Good Practice Recommendations The home should organise in-house social activities. (This was repeated from the last inspection). DS0000015007.V374149.R01.S.doc Version 5.2 Page 28 Kelvin Grove 2. YA32 The home should maintain accurate individual training records. (This was repeated from the last inspection). Arrangements should be made to clean all stained carpets and bathroom floors. All staff files should be up to date and be made available for inspection 3. 4. YA25 YA34 5 YA34 In order to ensure people using the service are protected the home should undertake staff Criminal Record Bureau (CRB) checks at least once every three years. Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kelvin Grove DS0000015007.V374149.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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