Inspection on 07/03/07 for Kelvin Grove

This inspection was carried out on 7th March 2007.

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 3 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 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 09/07/2008.

CARE HOME ADULTS 18-65 Kelvin Grove 18 Rothsay Road Bedford Bedfordshire MK40 3PN Lead Inspector Jacqui Barry Unannounced Inspection 7th March 2007 11:05 Kelvin Grove DS0000015007.V332766.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.V332766.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.V332766.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 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.V332766.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2006 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.V332766.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out over 4 hours by two Regulation Inspectors. This report has been written using evidence gathered during the inspection, which included; a tour of the building, looking at records, discussions with service users, the manager, several members of staff and a visiting Community Psychiatric Nurse. Information has also been collected from questionnaires, which service users completed before the inspection. What the service does well: 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. The summary of this inspection report can be made available in other formats on request. Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 Page 6 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.V332766.R01.S.doc Version 5.2 Page 7 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): 2 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Service users benefited from having their needs assessed before moving into the home. EVIDENCE: One new service user had moved into the home since the last inspection and evidence showed that sound pre-admission assessment procedures were in place. Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 Page 8 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 & 9 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Service users were consulted about their support plans and could take risks as part of an independent lifestyle. EVIDENCE: Two service user support plans were looked at. Each one included details about how the home intended to meet service user’s individual needs in the short and longer-term. Service users had been consulted about their support plans and had signed to indicate that they were in agreement with what had been recorded. All of the service users who completed the inspection questionnaire before the visit said that they were able to make choices over aspects of their lives. One service user spoken with during the inspection felt that the staff gave her enough support and knew that she could speak with her key-worker at any time if needed. Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 Page 9 Risk assessments were in place for a range of activities and included specific guidelines, meeting the previous requirement. One member of staff spoken with stated that he was involved in assisting service users with their daily tasks and supporting them to access appointments and attend meetings with healthcare professionals where required. Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Service users had opportunities for personal development, but in-house social activities were limited. EVIDENCE: During the inspection services users independently organised their routines within and outside of the home. Fewer activities were happening in the evenings and the manager was mindful of this. There was a plan for a newer member of staff to take on organising social activities and this should be given priority. One service user spoken with said that she attended various day-services and often went into town independently. Another service user spoken with was going on a trip out with a support worker and said that he liked visiting places Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 Page 11 of interest within the local community. Services users families were invited to visit the home. Staff spoken with confirmed that service users were encouraged to participate in life in the home and were expected to undertake household chores, although they could choose not to take part. Service users were encouraged to make suggestions about the menus and those spoken with said that they liked the food served. Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Service user’s health, social and emotional needs were continually monitored and well met. EVIDENCE: Individual support plans showed that service user’s behavioural and healthcare needs were monitored. Staff had been trained in administering medication and the records seen were clear and current. The Community Psychiatric Nurse spoken with was very positive about the level of care provided by the home and felt that the staff used a flexible approach in their work with service users. Staff interviewed referred to the importance of offering service users personal support in such a way as to preserve rights and dignity; examples of which were observed during the inspection. Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. The home had a satisfactory complaints process, although records must be maintained showing how complaints have been dealt with. EVIDENCE: One service user spoken with was clear that he would be able to raise any complaint with the manager and felt that the staff always listened to him. No complaints had been made since the last inspection. There was no information to support what action had been taken in relation to previous complaints and this was discussed with the manager. One member of staff spoken with had received training in the protection of vulnerable adults. Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 Page 14 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 & 30 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Improvements had been made to the standard of accommodation and further investment was needed to redecorate/refurbish other areas of the home. EVIDENCE: At the last inspection, a statutory requirement was made for the home to provide dates to the Commission for Social Care Inspection of when redecoration would take place. On this visit two new fridges had been purchased and redecoration had been carried out in the downstairs bathroom/shower room. The home was generally clean and tidy and bedrooms had been personalised. However, greater investment was needed to replace kitchen flooring, redecorate and refurbish bathroom 2 and repair the outside wall, which gave a poor initial impression of the home. A maintenance plan is still required. Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 & 35 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Residents were supported by a committed and competent staff team. EVIDENCE: One member of staff spoken with commented that he enjoyed working in the home and was keen to promote a more independent style of living for service users. A member of agency staff who had been working at Kelvin Grove for 12 months stated that he really liked supporting service users and was committed to improving outcomes. The staff training plan seen included dates for arranged sessions but there was no evidence as to whether all staff were actually present for each event. The manager agreed to put in place individual training records for each staff member in order that training needs could be monitored. At the last inspection, statutory requirement was made in respect of staffing ratios. During the inspection, there were sufficient staff on duty to meet the Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 Page 16 needs of service users, although there was heavy reliance on agency staff; more agency staff hours were used in an 8 week period than permanent staff. The manager reported that efforts were being made to address the staffing problem and a staff member from another of the company’s homes was going to be working at Kelvin Grove to support the manager. Overall, staffing levels were satisfactory. At the last inspection, a statutory requirement was made for the home to have waking night staff to monitor the needs of one service user. This issue had been addressed and waking night staff was no longer required. Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. The home was well managed. Fire safety must be given a priority. EVIDENCE: Service user’s views and feelings were constantly monitored by the staff team. It was positive to see that service user meetings had been used positively to discuss important issues such as racism. These meetings should however take place more frequently. Quality assurance systems were in place and the management of the home was consistent and sound. The manager should apply to the Commission for Social Care Inspection to become the Registered Manager without delay. Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 Page 18 There was evidence to show that fire safety testing had been carried out at the required intervals. However, three communal fire doors were wedged open presenting a fire safety risk. The manager advised that doors had been propped open to monitor service users. The manager was advised to seek guidance about options that would allow fire door to be kept open safely to monitor service users, but that would not present a fire risk. An immediate requirement letter was left with the manager who removed wedges and chairs from fire door entrances during the inspection. Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 Page 19 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 3 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 Page 20 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 YA22 Regulation 22 Requirement Timescale for action 07/03/07 2 YA24 13 & 16 3 YA42 23 The registered person must be able to provide written evidence to confirm that complaints have been fully investigated. Not met, carried forward to the next inspection. 31/05/07 The registered person must provide dates for when the redecoration of the home is to be started. Supply this information when sending in the action plan. Not met, carried forward to the next inspection. The registered person must 07/03/07 make arrangements for containing fires. 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 YA12 YA32 Good Practice Recommendations The home should organise in-house social activities. The home should maintain accurate individual training DS0000015007.V332766.R01.S.doc Version 5.2 Page 21 Kelvin Grove 3 4 5 YA37 YA39 YA42 records. The manager should apply to the CSCI to become the Registered Manager. Service user meetings should take place more frequently. Ensure that all staff undertakes fire drills. Not inspected, carried forward to the next inspection. Kelvin Grove DS0000015007.V332766.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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