Inspection on 30/08/05 for Kelvin Grove

This inspection was carried out on 30th August 2005.

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 no outstanding requirements from the previous inspection report, but made 2 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 20/02/06

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 Announced Inspection 30th August 2005 09:30 Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 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.V251664.R01.S.doc Version 5.0 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.V251664.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kelvin Grove Address 18 Rothsay Road Bedford Bedfordshire MK40 3PN 01234 217287 01234 217287 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) Together Working for Wellbeing NBHA Chilterns Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11Th January 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 MACA (Mental Health After Care Association) 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.V251664.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced inspection took place over 6 hours. The manager Jo Forrest was present at the inspection. The inspection comprised of a tour of the bedrooms, bathing facilities and the communal areas of the home, care tracking in relation to two service users and conversations with some of the service users, staff and the manager. The inspector also spoke to a family member of a service user. What the service does well: The manager and staff had worked very hard to meet the standards. The staff advocated well on behalf of service users by accompanying them to their appointments. They also promoted service users rights by putting their views forward at meetings, and GP visits. Service users are supported to read their daily notes that are written by staff. They sign the records to say that they have read them. Service users’ meetings are held regularly and the running of the home is discussed with them. The staff enjoyed working at the home and with the service user group. It was also stated that they all worked well as a team. The training provided by the organisation was good and linked to meeting service users needs. Service users spoken to stated that they liked the meals and they were given choices for food. They also enjoyed the activities in the home and at day care services. They found the staff nice and helpful. The staff was meeting the health care needs of service users, and the home had good working relationships with health professionals. Service users were involved in fire drills and all staff had received training on fire safety. The home had started to develop their main policies in a user friendly language for service users to understand. Positive comments were received from a family member of a service user about the care provided by the home. Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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.V251664.R01.S.doc Version 5.0 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.V251664.R01.S.doc Version 5.0 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): The homes statement of purpose and service user’ guide provided prospective service users and their families information of the services the home provides enabling an informed decision about admission to the home. EVIDENCE: The home had a statement of purpose and a service users’ guide. This gave detailed information on the facilities and services that are provided by the home. Experienced staff assessed new service users in their own environment and obtained information from social services and health professionals. The initial assessment form was completed in pencil and not fully completed. Service users and their relatives were encouraged to visit the home prior to admission. Service users spoken to stated that they had visited the home before they decided to move in on a permanent basis. It was stated that overnight visits were also offered to service users and most of them had this to help them make a decision to come to the home. A one-month settling in period was offered and this was extended when needed. The home did not accept emergency admissions. All the service users had contracts and they signed these. Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 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): There was care planning systems in place to provide the staff with the information they needed to meet the needs of the service users to a high standard. The risk assessments for service users needed expanding to meet all risks identified to safe guard them from injury or harm EVIDENCE: The service users’ files inspected had individual care plans and these were signed by the service users. However the plans were not signed and dated by the people involved in drawing these up. The plans had identified needs and goals to be achieved and were being reviewed regularly. The information in some areas needed expanding as discussed at the inspection. The service users completed client progress reports and annual review of needs with support from staff. This was good and provided evidence to show how service users were involved in their care. The in house review forms must be dated and signed by the person completing the form. One service user stated that they were very involved in their care and made decisions that affected them, and they enjoyed being involved. The home had a new format for recording risk. There were some risk assessments identified in the service users’ file. However risk assessments were not undertaken for all risks that were Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 Page 10 identified when reading service users notes. The staff spoken to were aware of the risk assessments for service users that were case tracked. The staff were observed giving service users advice, information and assistance to make decisions about their lives. They also had a checklist of information that was discussed and given to service users when they came to live at the home. For example the complaints procedure, service user guide, confidentiality and other information about the home was also discussed. Service users spoken to stated that they made decisions and asked staff for their advice. Advocacy services information was displayed on the information board and a clinic was held twice a week. Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 Page 11 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): Service users have opportunities for personal development to enrich their social and educational opportunities. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: One service user spoken to stated that they went to day care services and enjoyed this. The service user also stated that the food was very nice and the staff were very good. Service users were encouraged by staff to make decisions by giving them choices. This was observed on the day of the inspection. The home held weekly service users’ meetings and discussed policies and issues that affected them in the home. They were also involved in the recruitment of new staff and of potential service users moving into the home. Service users spoken to stated that they helped choose the décor of the home and of their bedrooms. They also decided the activities and menus in their weekly meetings. The staff stated that service users were given the opportunity to read their notes in their files and this was confirmed by checking one service users file, which was signed by them to state that they Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 Page 12 had read their notes. Some of the service users helped with gardening and they also participated in the domestic chores. A kitchen was also available for service users who had reached the independent level to prepare simple meals. One service user who had prepared her meal stated that she enjoyed cooking. In the summer months the home had Barbeques at the rear garden. The activities in the home included playing music, baking cakes, reading, playing bingo, having a foot spa, barbeques, and talking to staff and service users. Service users also went to the pub, shops, parks, and church. The service users also went out on day trips with day care services and with the home. The home had a policy on visits and this information was available in the service users guide. The home encouraged family/friends involvement in the home with the permission from the service users. The inspector spoke to a service users’ family and positive feedback was given about the home. Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 Page 13 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): The knowledge of staff, safe systems for administering medication and detailed care planning meant that the health needs of service users are met. EVIDENCE: The service users’ files that were case tracked had information on service users personal and medication needs. Service users spoken to stated that they choose their own clothes and used the community hairdressers. The staff spoken to gave a detailed account of how they met the personal and medical needs of the above service users files inspected. Charts were kept for a service user who had behaviour problems and the information was analysed and discussed with the GP. However there were some charts on weights that were not completed at all times. Service users visited the health professionals and this was recorded in the daily notes and in the main diary. It was recommended to the manager that the home should start an appointments chart in the service users file to record these appointments. The manager agreed this. All service users had signed the medication consent form to agree to their medication being administered by the home. All staff who gave out medication had received this training. Staff were signing the medication sheets when they administered service users medication. The home had good links with the Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 Page 14 health professionals, day care services, and the GP’s. The staff had received training on illness and death. Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 Page 15 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): The staff have good knowledge and understanding of adult protection issues, which protect service users from abuse EVIDENCE: The home had policies and procedures on Adult Protection and whistle blowing. A copy of the complaints policy was available in the service users’ guide and a copy was given and explained to service users when they first came to the home. The service users spoken to stated that they knew who to speak to if they were unhappy about their care. The staff had also discussed the adult protection policy with the service users and they were trying to get some of the main policies developed in a language the service users could understand. All the service users were able to communicate verbally and it was stated that they were able to complain if they had any concerns. The staff spoken to understood adult protection procedures and stated that if they suspected any abuse; they would report it to management. Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 Page 16 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): The manager has a good understanding of the areas in which the home needs to improve. Planning was in place but there were no dates recorded to state when this work was to start. EVIDENCE: The home was located within walking distance to the local amenities, local transport and relevant support services. The premises were in keeping with the local community and had a style and ambience that reflected the homes purpose. Service users were observed accessing the communal parts of the home safely. The home was clean and had a homely feel to it. However it was stated and 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. One of the service users Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 Page 17 bedrooms seen was individualised to their needs. The service user had chosen the colour of the room and the furniture. The home had a nice garden, however the plastic furniture in the garden needed replacing Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 Page 18 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): Staff morale is good, resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. EVIDENCE: The home had been very short staffed. The vacancy hours of a full time deputy manager, one social care worker and one relief staff position had been filled, and the staff were due to start in September 05. At present the same two agency staff worked the vacancy hours. This provided continuity to the service users. The staff files inspected had all the information required in the standard. The staff spoken to also stated that they were given job descriptions, and good inductions to the home. It was also stated that the organisation provided good training. One staff spoken was a qualified community psychiatric nurse who had lots of experience of working with service users with mental health needs. It was stated that they enjoyed working with the service users and with the team. Management support was stated to be good, and team meetings were held regularly and these were also noted to be good. The team away day was described as being very useful and enjoyable. The staff also stated that the service users received a good service from the home. They also received supervision from management and this was very good. Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 Page 19 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): The home is run in the best interest of the service users and this results in practices that promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: A risk assessment on the building was undertaken. All the staff had also received training on fire safety and safe working practices. The service users spoken to stated that they were involved in fire drills and knew what to do if there was a fire in the home. The fire officer had visited the home in June 2005 and this visit was satisfactory. A representative from New Leaf housing association informed the inspector last year that they were waiting for quotes for getting either magnetic doors or pneumatic doors for the home. The fire officer had made this recommendation and it was still outstanding. The manager stated that this was being dealt with by the housing association. Fire alarm testing and emergency lighting was also carried regularly. Evidence showed that the manager and staff worked hard to meet the needs of the service users. It was stated that the manager had an open door policy and staff and service users found her very supportive. Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 Page 20 Kelvin Grove DS0000015007.V251664.R01.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 x X x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kelvin Grove Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 3 x DS0000015007.V251664.R01.S.doc Version 5.0 Page 22 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 20/12/05 2 YA24 13,16 The registered person must ensure that risk assessments are undertaken on all risks that are identified with the service users. The registered person must 20/10/05 provide dates for when the redecoration of the home is to be started. Supply this information when sending in the action plan. 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 YA2 Good Practice Recommendations Ensure all assessments are completed by using an ink pen, and all forms are signed and dated by staff. 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