Inspection on 10/07/07 for Kempsfield

This inspection was carried out on 10th July 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kempsfield 03/10/06

Kempsfield 31/10/05

Kempsfield 11/07/05

Kempsfield 31/08/04

Kempsfield 22/04/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Kempsfield Primrose Drive Sutton Park SHREWSBURY Shropshire SY3 7TP Lead Inspector Sue Woods KEY Unannounced Inspection 10th July 2007 09:30 Kempsfield DS0000032578.V339735.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 Kempsfield DS0000032578.V339735.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. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kempsfield Address Primrose Drive Sutton Park SHREWSBURY Shropshire SY3 7TP 01743 246033 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) Shropshire County Council Debora Susan Mowl Care Home 19 Category(ies) of Learning disability (17), Learning disability over registration, with number 65 years of age (2) of places Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate service users with a learning disability who are aged under or over 65 years in any proportions. That the manager attends training in local adult protection procedures and be aware of her role within that process within six months. 3rd October 2006 Date of last inspection Brief Description of the Service: Kempsfield is registered with the Commission for Social Care Inspection to provide accommodation and personal care for up to nineteen adults with a learning disability, to include two people who are over the age of 65. The home is owned and managed by Shropshire County Council. The Responsible Individual is Mr Adrian Johnson, Operations Manager, and the Registered Manager is Ms Debora Mowl. The home is located on the edge of Sutton Park, a private residential estate situated on the outskirts of Shrewsbury and is within an easy distance of local amenities such as shops, a church, cinema, college, pubs and medical facilities. The home is a two-storey building and has been converted into three long-term ‘flat’ type units known as Sabrina, Kingfisher and Primrose. Within each unit the home seeks to provide a positive homely environment for service users affording the appropriate levels of support required to meet their individual needs. Consultation with people who live at the home takes the form of regular meetings, discussions and involvement in the development of care plans. Advocacy services are promoted and family members are also consulted in how they feel the home is run. Fees charged per person were unavailable at the time of the inspection. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Kempsfield took place on 10th July 2007 from 09.30 am until 02.15 pm. The inspection reviewed all 22 key standards and information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. As part of the fieldwork activity the inspector met with service users and staff from the home and from the day service. Questionnaires were left for all staff to complete and return if they wished. Three were completed at the time of the inspection. Two were returned following the inspection. The manager was on annual leave on the day of the inspection visit however the assistant manager was available throughout and proved to be very competent and knowledgeable about the people who live at Kempsfield and the homes itself. The inspector reviewed three care files in detail and other documentation referred to within the report. Prior to the inspection visit the manager completed and returned an Annual Quality Assurance Assessment. Information contained within this document is referred to throughout this report. What the service does well: People who live at Kempsfield are supported by a team of committed and enthusiastic staff offer who offer ‘good care and support’. Staff feel valued and appreciated and the management team is very service user focussed. People who spoke with the inspector said that they liked living at Kempsfield and it was regularly described as ‘ a happy home.’ The manager of the home stated in the AQAA that ‘we listen to service users’ and have received ‘many excellent compliments’ from health and social care professionals. This was seen to be the case. Some staff felt that teamwork is a strength of the service, as well as the knowledge of the staff in relation to the individual needs of people who live at the home. A health care professional recently described the staff team as ‘kind and caring’, ‘dedicated and determined’. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 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 Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place that would enable the successful admission of a new service user to the home. EVIDENCE: Since the time of the last inspection of Kempsfield one person has been admitted as part of a planned move. His file was reviewed and contained detailed assessments of need from a number of health and social care professionals. These assessments have formed the basis of his care and support plan. The assistant manager stated that Kempsfield do not accept emergency admissions. Work is in progress to develop contracts in a user friendly format. Draft documents have been seen by the inspector. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 6,7 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care-planning systems are in place to provide staff with the information they need to meet the assessed needs of people who live at the home. People are supported to make decisions and to take responsible risks. EVIDENCE: Three care plans were reviewed by the inspector as part of the inspection activity. All files contained essential information in relation to the care and support needs of the individuals and in conversations with the a service user, staff and the assistant manager it was evident that the care plan reflected the needs and wishes, likes and dislikes of the person. Long, medium and short term goals are clearly identified and those seen reflected that a number of these goals had been achieved. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 Page 10 Staff, at the time of the inspection, were very supportive of the individual wishes of the people they were supporting offering choices about the activities they were planning and what they would like for dinner. Minutes for residents meetings were seen on files reviewed. Regular meetings are supported by the local self advocacy group and outcomes are fed back to the management team. Minutes were seen to be in a user friendly format and detailed, for example, activities and holidays. Risk assessments seen had all been reviewed recently. Manual handling assessments supported the use of aids and adaptations although it was found that guidance stated on two occasions that the hoist should be used by two staff. The assistant manager stated that this was not accurate. She committed to review the assessments. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at Kempsfield benefit from varied daytime opportunities. Family links are supported and maintained and people are provided with a varied and balanced diet in accordance with their personal preferences. EVIDENCE: Service users access local day services on a regular basis. In addition there is a day service organised within Kempsfield for people who live at the home. The inspector met the group at the time of the inspection as they prepared for a day trip to a local beauty spot. Two people remained at the home with a member of staff. Activity sheets, on care files reviewed, identified very minimal activities take place outside of the home although feedback from staff suggests that activities Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 Page 12 are good. One person who lives at Kempsfield told the inspector how she loves to do jigsaw puzzles. People who live at Kempsfield are supported to maintain contacts with family and friends. At the time of the inspection a family member phoned the home to say how happy he was with his son’s progress. Kempsfield was last year awarded the Gold Healthy Eating Award. Menus seen on each flat reflected a varied diet with choices available. On the day of the inspection the cook had prepared the favourite food of the woman who had not gone out on the day trip. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 18, 19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at Kempsfield benefit from appropriate support from staff and health care professionals. People are safeguarded by the home’s system for handling, storing and administering medication EVIDENCE: Staff feel that the home does well at supporting people to meet their personal care needs. Staff work creatively to ensure people who live at Kempsfield have the best possible care and support. Care plans detail health care appointments and health action plans were seen on all files reviewed. A relative complimented the home at the time of the inspection in relation to the support that staff have given in relation to personal and health care needs. The care plan supported staff input and success. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 Page 14 Individual plans are available to support identified behaviours and feedback from the assistant manager suggested that these are proving effective. Medication arrangements were reviewed for two random areas of the home given that the home’s AQAA suggests numerous improvements have been made in this department. Records were seen to be well organised and up to date and guidance in relation to identified medications were seen on individual care files. Training records suggest that 12 staff have now completed medication training and the assistant manager stated that the rest are currently doing it with a local college. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at Kempsfield are protected by an effective complaints procedure and effective systems of safeguarding peoples money. EVIDENCE: Since the time of the last inspection of Kempsfield the assistant manager stated that here have been no complaints received about the service provided at the home. Issues in relation to financial irregularities were fully explored at the time of the last inspection of the home and the assistant manager was able to confirm that new procedures are robust and effective in terms of monitoring. During the inspection the inspector was able to observe a staff member request money for an impromptu outing and this was actioned with appropriate records made to support the transaction. Staff feel that the process is efficient. Kempsfield has received a number of compliments in relation to the service provided and the assistant manager shared these with the inspector. People complimenting the service include a relative, a senior line manager and a health care professional who described the staff team as ‘kind and caring’, ‘dedicated and determined’. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are provided with a clean, comfortable and homely place to live. EVIDENCE: Kempsfield has benefited over recent months from a number of improvements made to the environment. Areas of development within the home have been identified within the conditions report although timescales are typically between 3- 5 years. However works are taking place. Radiators have all been replaced recently with ones that have individual thermostatic controls. The kitchen in Sabrina Flat was refitted last week and the assistant manager reported that it has greatly improved the standard of accommodation within the unit. Bedrooms seen by the inspector were attractively decorated and were very personalised. It was reported that people choose their own colour schemes. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 Page 17 The homes AQAA identifies the bathrooms as an area where the home can do better. Staff supported this comment in written feedback. On the day of the inspection the service manager rang the assistant manager and stated that the costing for this project is now completed. The AQAA also suggests that training of staff in infection control, COSHH and Health and Safety is an area where the home does well. Staff training records reflect this and on the day of the inspection all areas of the home were clean with evidence of personal protective equipment readily available. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34 and 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users benefit from being supported by competent and committed staff. Service users are protected by satisfactory recruitment and selection procedures. Service users may benefit from additional resources (time and staffing) being available to support activities and safety may be compromised if adequate staffing levels are not implemented. EVIDENCE: Staff who spoke with the inspector were knowledgeable about their roles and were seen to be motivated and enthusiastic. Written feedback reflected these findings and staff felt that ‘good care’ was a strength of the home. Staff felt well supported. Staffing levels were discussed in relation to the use of agency staff within the home. Although permission to use agency following authorisation from senior Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 Page 19 management has been granted the procedure is time consuming and is on occasion is refused (as stated in the AQAA). The manager continues to raise concerns in relation to staffing issues within the home. Some risk assessments seen suggested that hoists need to be operated by two staff members although the assistant manager wasn’t convinced that this was necessary. If two staff are required then staffing levels would need to be reviewed to facilitate this. Managers are currently required to administer medication and assist during interventions requiring higher staff support. Areas for improvement identified by staff included more money and more staff so people who live at the home can go out more. Staff training files were seen to be very well organised and all essential information to support that staff receive all mandatory training opportunities was available. The training matrix also identifies when refresher training is due. Staff recruitment procedures were inspected on 13/07/06 and were found to be satisfactory. There have been no staff appointed to the home since the time of the last inspection. One person who lives at the home told the inspector that she ‘likes the staff’. One person named staff who she is especially fond of. Staff told the inspector that they feel valued and appreciated. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 Page 20 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): Standard 37, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users and staff benefit from a knowledgeable and proactive manager who operates well within the constraints of the service. Health and safety is promoted and protected within the home. EVIDENCE: Although the manager of the home was on annual leave on the day of the inspection she did complete and return the homes AQAA that demonstrated that she was aware of the strengths and needs of the service and that she proactively raises issues in order to improve the quality of the service provided. The manager was described by a staff member as being ‘the best’ commenting that ‘service users come first’. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 Page 21 The assistant manager, who was on duty at the time of the inspection, was very knowledgeable about the home and the people who live in it. Visits by the head of services for adults with learning disabilities take place on a regular basis and reports are produced. The report seen following the visit on 31/05/07 concluded that ‘the home is well run’ and the inspector would support this comment. Issues in relation to time constraints on the management team remain ongoing and the manager continues to raise these concerns with senior managers. The manager feels that given more time the service could improve monitoring systems. The homes recent health and safety audit was positive (as per the AQAA) and the assistant manager showed the inspection actions already taken to address issues identified. On 18/12/06 CSCI received a report from the fire officer after a visit on 6.12.06. The report stated that all matters relating to fire safety appear to be satisfactory. Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 Page 22 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 Page 23 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 (4) (c) Requirement The home must review assessments in relation to the number of staff required to offer effective and safe support to people using aids and adaptations. This is because someone may get hurt if staff do not follow safe guidelines. The home must have sufficient staff deployed on each unit to meet the individual needs of the people accommodated at all times. This is to make sure that people get safe support at all times Timescale for action 13/08/07 5. YA33 18(1)(a) 13/08/07 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 YA37 Good Practice Recommendations It is again strongly recommended that the manager be given additional time of rota to enable her to effectively fulfil her role and responsibilities of registered manager. DS0000032578.V339735.R01.S.doc Version 5.2 Page 24 Kempsfield Kempsfield DS0000032578.V339735.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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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