Inspection on 20/02/06 for Kelvin Grove

This inspection was carried out on 20th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kelvin Grove 10/02/09

Kelvin Grove 07/03/07

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 09/07/2008.

CARE HOME ADULTS 18-65 Kelvin Grove 18 Rothsay Road Bedford Bedfordshire MK40 3PN Lead Inspector Ansuya Chudasama Unannounced Inspection 20th February 2006 10:35 Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 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.V270897.R01.S.doc Version 5.1 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.V270897.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kelvin Grove Address 18 Rothsay Road Bedford Bedfordshire MK40 3PN 01234 217287 01234 217287 www.together-uk.org www.together-uk.org Together Working for Wellbeing NBHA Chilterns Vacant 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.V270897.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2005 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 well being and New Leaf Housing Association is responsible for the building. The home provides residential care for 12 service users with mental health needs. All the bedrooms are single and met 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.V270897.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours. The manager and the area manager were present at the inspection. The inspection comprised of a tour of the communal areas, talking to staff, and to the some of the service users living at the home. The home had 8 service users in the home and one of the service users was in hospital. The home had four vacancies. It was stated that potential service users had been assessed for these vacancies. This report should be read in conjunction with the last inspection report undertaken on the 30th October 2005. What the service does well: What has improved since the last inspection? Three of the service users bedrooms are been decorated. Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 None of the standards were assessed on this occasion but these were all assessed at the last inspection. EVIDENCE: Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 None of the standards were assessed on this occasion but these were all assessed at the last inspection. EVIDENCE: Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13, Service users are given opportunities to get involved in appropriate activities to ensure that their independent living skills are developed EVIDENCE: The staff spoken to stated that service users were encouraged to help with cooking, and cleaning. Two service users spoken to stated that they had been living at the home for a few years. It was stated that they felt safe most of the time at the home. They stated that it would be nice to have the lounge decorated. One service user had been at the home for eight years and it was stated that “its ok here”. The staff were described as being nice. One service user stated that they enjoyed walking and they had seen their care plan and read their daily notes. One service user stated that they did their shopping and cooking with help from their link worker. The service users spoken to stated that they had been informed about the decoration of the lounge and they had chosen the colours. Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 None of the standards were assessed on this occasion but these were all assessed at the last inspection. EVIDENCE: Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 None of the standards were assessed on this occasion but these were all assessed at the last inspection. EVIDENCE: Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Some of the homes furnishings, and fittings needed replacing to ensure that service users live in comfortable bright and pleasant surroundings. EVIDENCE: This standard had not changed since the last inspection. “Observation showed that the communal areas needed refurbishing to make them pleasant. Some of the furniture in the rooms also needed replacing as they were old and worn out. This was discussed with the manager who stated that they had been given a budget for the modernisation of the home. The service users had been consulted with this and they were involved in prioritising the areas first to be completed. A copy of the redecoration plan for 2005 and 2006 was seen. However there were no dates recorded when each of the areas were to be started or completed or when New Leaf housing association was going to complete the tasks that they were responsible for repairing. A tour of the home also identified areas that needed looking at but this was not included in the redecoration plan”. Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 14 The area manager and the manager informed the inspector that they were going to go around the house and would provide detailed information with dates of when this was to be done. The inspector was informed that three service users bedrooms had been decorated. However there was no evidence to show when this was done. The home needs to have a planned maintenance and renewal programme for the fabric and redecoration of the premises, with records kept. Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35 The homes recruitment procedures ensure that service users are protected from abuse. The staffing ratio to service users was not being met and therefore this put service users at a risk. EVIDENCE: The inspector was informed that the home had been very short staffed for the past five months. The home had recently appointed a full time support worker and they were waiting for CRB checks clearance. The home still had vacancies for two full time support workers and one 20 hours cook position. The home had one member of staff who was on holiday for seven weeks. The home used agency staff and their profiles were obtained prior to starting employment. It was also stated that they received a good induction when they started. The home did not employ a cleaner. The staff carried out this task. The home had two relief staff who also worked the vacancy hours at the home. The home had 8 service users in the home and one of the service users was in hospital. The home had four vacancies. It was stated that potential service users had been assessed for these vacancies. However the home was still waiting for the paperwork from the funding authority to come through. The inspector was informed that one service user who was unwell was getting up in the middle of the night. The staff who did a sleep in duty had to get up Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 16 several times in the middle of the nigh. This was to ensure that the service user was safe. The staff also worked the next day. The home must ensure that staff who had been up during the night do not work the next shift in the morning. This is to prevent any accidents or mistakes being made due to not having enough sleep. The inspector was informed that the service user was unsteady on her feet and had fallen twice in the past. It was also stated that the service users risk assessment undertaken showed that the person was at a high risk. The service user needed one to one support when unwell and for personal care she needed the support of two staff to help with bathing. The manager needs to look at the ratio of staff to service users. Also a waking night staff was required for the service user who was unwell and was getting up in the middle of the night. The inspector was informed that the service user was being re assessed by a social worker and they had already asked the funding authority to pay for a waking night staff. It was stated that the staff did not have enough time to do the paperwork due to staffing problems. The home had four service users that they supported in the community. The home provided 19 hours of outreach support per week to these people. The staff at the home covered these hours and it was the permanent staff who attended to these people. This has meant that when the home was short staffed, agency staff were used. The home must provide continuity of staff to the home. It was stated that appointments had been cancelled and service users had also attended appointments on their own because there were not been enough staff on duty. The staff at the home undertook the statutory training in safe working practices. They also attend training in mental health, medication, POVA, diversity, and equal opportunities. One staff had NVQ level 2 and the person was waiting to undertake NVQ level 3. Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,42. EVIDENCE: All the staff had done the fire safety training. The fire book checked was satisfactory. The staff were informed what to do if there was a fire in their induction training. One of the staff spoken to had not been involved in a fire drill at the home. The manager needs to ensure that all the staff are involved in the homes fire drill. The area manager undertook regulation 26 visits on a monthly basis. This also included looking at areas of the home for quality monitoring purposes. Those seen were not very easy to understand. However these systems had not been coordinated into one formal quality monitoring process. There was not a written development plan for the home, which is renewed annually. The area manager informed the inspector that this would be undertaken. Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 18 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X x X X 2 X X 3 X Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 19 Yes Are there any outstanding requirements from the last inspection? 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 YA9 Regulation 13 Requirement Timescale for action 20/05/06 2. YA24 13,16 3 YA33 18 4 YA33 18,13 The registered person must ensure that risk assessments are undertaken on all risks that are identified with the service users. Not assessed on this occasion but the inspector was informed that a new format for risk assessments were being introduced by the organisation. The registered person must 20/05/06 provide dates for when the redecoration of the home is to be started. Supply this information when sending in the action plan. This requirement date of the 20/10/05 was not met. The registered person must 20/04/06 reassess the staffing ratio to service users to ensure their needs are being met. The registered person must 20/04/06 provide a waking night staff to monitor the needs of service users who are unwell. Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 20 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 YA42 Good Practice Recommendations Ensure that all staff undertakes fire drills. Kelvin Grove DS0000015007.V270897.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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