Inspection on 03/10/06 for Kempsfield

This inspection was carried out on 3rd October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 29 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kempsfield 10/07/07

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 Rebecca Harrison Key Unannounced Inspection 3rd October 2006 10:40 Kempsfield DS0000032578.V296554.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.V296554.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.V296554.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.V296554.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. – Condition met on 07.06.05 31st October 2005 Date of last inspection Brief Description of the Service: Kempsfied 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. The aims and objectives for the home are included in the Statement of Purpose which include: ° Ensuring the service offers choice and independence incorporated into everyday living experiences. ° To provide a warm, caring environment that is both stimulating and supporting to service users. ° To improve the individuals’ quality of life by exploring day-to day living experiences in a positive and meaningful way. Potential service users and their representatives are able to gain information about this home from the Statement of Purpose available at the home. A Service User Guide is available and partly produced in a pictorial format. CSCI reports for this service can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk Staff on duty were unaware of the current range of fees charged per person. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started at 10.40 a.m. and was carried out by two inspectors over a period of eight hours. The inspection included talking with a number of service users present at the home, the staff on duty, looking in detail at all aspects of care for two people most recently admitted to the home, observing work practices, reviewing a number of records and a full tour of the home. 22 key National Minimum Standards for Younger Adults were assessed in addition to Standards 1,5,27,36 and 38 and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The purpose of the inspection was to assess ‘Key’ National Minimum Standards and to review the progress made by the home since the last inspection undertaken on 31st October 2005 when eight requirements were made. The registered manager was not on duty on the day of the inspection. Two of the assistant managers were in charge of the home and provided full assistance with the inspection of this service. What the service does well: People living at Kempsfield continue to be supported by a stable, enthusiastic and committed staff team who have a clear understanding of their individual needs. Staff are provided with good training opportunities and the home has exceeded the 50 target for care staff qualified to NVQ level 2 Standard. Staff and service users spoken with were complimentary in relation to how the home is managed. People who use the service are provided with good opportunities to develop their social and educational skills and access a range of community facilities and services. It is evident that family links are maintained and that the relatives of the people living at the home are encouraged to visit and are also invited to partake in social events arranged by the home. Service users are involved in aspects of making choices and their views listened to. A service user informed the inspector that a residents meeting had been held the previous night and the meeting was good. Service users also have access to an independent advocacy service. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although people living at the home are provided with a comfortable, clean and homely place to live the bathing and shower facilities are in need of investment as identified at the previous inspection last year. A planned maintenance and renewal programme needs to be developed and actioned to bring such facilities up to an acceptable standard and provide people with a more pleasant environment to attend to their personal care needs. This and the previous inspection identified a risk of scalding to service users from hot water outlets in bathrooms and bedrooms. During the inspection urgent action was taken by the home to safeguard people in the interim and following this inspection thermostatic controls have since been fitted to all sinks and baths as required. Staff should continue to monitor and record temperatures to ensure they do not exceed the recommended safe temperature. Care planning and risk management systems need to be improved to ensure that staff are provided with sufficient information and consistent in their approach to meeting peoples needs. The home needs to review its medication and health and safety procedures to ensure that the health, safety and welfare of service users and staff is fully protected and promoted. The Statement of Purpose needs to be reviewed and updated to include the homes policy and procedures for emergency admissions and contracts developed with service users, which accurately reflect their placement. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users are only admitted to the home following a comprehensive assessment of need. Service users are not provided with sufficient information about their terms and conditions of residency. EVIDENCE: An assistant manager reported that since the last inspection three people have been admitted to the home, one on a long-term basis and two people on a short-term basis. The home has an admissions policy in place, however the policy and procedure for emergency admissions is not stated in the admissions policy nor is it clearly stated in the homes Statement of Purpose or Guide. There was clear evidence that the home had obtained Community Care Assessments and these were available on two files reviewed. At the previous inspection it was identified that the home had not produced a satisfactory ‘statement’ setting out the terms and conditions of residence between Kempsfield and each service user to ensure that all concerned are clear about what is specifically being provided. Contracts were available on the files of the two people reviewed during this inspection however the information is in need of updating as it refers to NCSC instead of CSCI and did not contain Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 10 the allocated room number. One contract stated that the placement is ‘permanent’ however discussions held with the service user and an assistant manager clearly evidenced that the placement was short-term as an alternative placement has since been sourced and that he had been placed as an emergency admission. Both the service user and an assistant manager had signed the contract. The contract held on behalf of another person had been signed by the registered manager and an assistant manager. There was no evidence available that people had been supported by their family, representatives etc with drawing up the contract. It was later reported that this contract was compiled by Shropshire County Councils Contracts Department and that the manager is pursuing a contract formatted in a user friendly format. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are not provided with sufficient information to ensure that the support needs of service users are fully met. Service users are appropriately supported with making choices and have access to independent advocacy service. Risk management strategies require further development to ensure that service users are supported to take responsible risks. EVIDENCE: The care documentation for two people most recently admitted to the home was reviewed and as previously stated both files contained a detailed needs assessment carried out by the local learning disability team. A Care/Life plan was available on the file of the person admitted to the home on April 2006, completed by the person’s relatives. Records evidence that the plan had not been reviewed and updated by the home since the person had been admitted to reflect any change of need, routines or impact on the change of Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 12 environment to include strategies to manage the person’s behaviour. Minutes of a review meeting were available which clearly evidence that the service user and significant others attended and that the persons relatives are very happy with the service provided. Discussions held with staff on duty and accident records seen evidence that the person’s behaviours have challenged the service, causing injury to two staff. Two members of staff spoken with reported that the person has settled into the home very well and they were confident that the home is able to meet the persons needs, however one staff expressed concern in relation to the home not having a behaviour management plan in place to ensure staff are consistent in their approach despite an increase in recorded incidents. An accident record seen dated 20.09.06 indicated that the Consultant Psychiatrist had requested that a referral be made to the Behaviour Intervention Team however no guidelines or a risk assessment had been developed in the interim. A Care/Life plan dated 07.08.06 for the person admitted in May 2006 was available on file and indicated that the person is able to attend to his own personal care needs with minimal assistance from staff. Short-term goals were also stated however there was no evidence of a formal review being held to discuss the placement. A letter, dated 30.09.06 was on file, which indicated that the person had been involved with a proposed move to a more appropriate placement, which was signed by the service user. During the inspection the Community Living Manager visited the home to accompany him to a trial visit to the proposed home. It was evident through discussions held with him that he was very much looking forward to moving to a more appropriate placement which will provide him with greater opportunity to maintain and develop his independence. The Community Care Assessment stated that ‘Carers need to be aware of a planned response strategy or behaviours may escalate to become unmanageable’. However there was no strategy available on file and the care plan contained minimal information regarding the management of behaviours despite an entry seen on a contact sheet indicating the person had exhibited behaviours that challenged and later required a period of hospital assessment before being discharged back to the home. Service users are able to access an independent advocacy service. Designated key workers and the relatives of service users also advocate on behalf of the people living at the home. Throughout the inspection people were actively supported in decision-making processes. A service user informed the inspector that a residents meeting had been held the previous night and that the meeting was good and that they are allowed to tell the staff what they want in the home. Minutes of these meetings have also been forwarded to CSCI and clearly evidence that people are encouraged to take an active interest in decision making. Assessments to support people with taking responsible risks were available on the files of the two people reviewed however these are in need of further Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 13 development. For example assessments were generic and lacked information for example a manual handling assessment for someone who is wheelchair dependent stated ‘may require two staff sometimes’ and the weight or height of the person was not stated. The control measures in place to support a person accessing the community independently were very basic and stated for the person to take his mobile telephone with him however the number was not stated and it also stated that he is only to travel to familiar places. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 14 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): 12,13,15,16 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 use the service are provided with opportunities to develop their life, social and educational skills. Family links are maintained, rights and responsibilities promoted and people provided with a varied diet in accordance with their personal preferences. EVIDENCE: On arrival to the home a number of people were out attending a variety of day services provided by the local authority. It was reported that two people access local college facilities. An in-house day service is also available for service users to access directly from home following the closure of Monkmoor day service. During the inspection a small number of people were supported to go out shopping to Telford and have lunch out whilst other people were supported with in-house activities, watching TV, listening to music and one staff member was supported to look through photo albums and past events which he clearly enjoyed. On the service users arrival back from their trip out one person reported that she’d had a lovely time out and had been to two Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 15 shops and enjoyed her lunch, which she chose herself. She was then supported to count the activity money up supported by a staff member. Contact with friends and family is well promoted and the visitors book evidenced that the home receives a number of visitors as evidenced in the contact sheets maintained on service user files. A visitor’s room is available for service users to meet with their visitors or they can see them in the range of communal areas provided or in the privacy of their own room. It was reported that the parents of one of the people case tracked play a very active role in her life and support her to access college courses. Staff spoken with stated that positive working relations have been developed between the home and relatives. Records seen and discussions held with staff on duty indicate that people are encouraged to develop their self-help skills as much as their ability allows. Staff were observed to maintain one service users independence by encouraging him to make drinks, lay the dinner table and clear away. Bedrooms are lockable and a service user spoken with confirmed that staff knock on his bedroom door prior to entry and it was evident that his privacy and dignity is upheld. . The home has very recently been awarded a Healthy Eating ‘Gold’ Award by the authority. The home employs one full-time and one part time cook. A three-week rolling menu is in place and people are provided with a choice of two meals. Menus seen indicate that people are provided with a balanced diet and adequate fresh fruit and vegetables were readily available. The cook spoken with had a clear understanding of preferred preferences and the dietary needs of the people accommodated and she was later observed consulting with people over the choice for evening meal. The cook stated that the she and her colleague also attend residents meetings to discuss their preferences and choice of menu. Preferences in relation to dietary needs and support requirements were seen on the two files reviewed. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 16 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): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. Systems for the management of medication are not sufficiently developed and potentially put service users at risk. EVIDENCE: Preferences in relation to personal support were documented on the file of the one person case tracked and the care plan for the other person indicated that the person is able to attend to his own personal care needs with minimal assistance from staff which was confirmed through discussions held with him. Health appointment records were available on the files reviewed and evidence that individuals have regular access to NHS healthcare facilities and the health of individuals is closely monitored. One person reviewed had been admitted to hospital for a reassessment. A physiotherapy report and evidence of a medication review was available on the other persons file. Health action plans have yet to be developed however a format is in place. Staff spoken with demonstrated a clear understanding of peoples support requirements and considered the home meets the healthcare needs of the people accommodated well. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 17 Performance outcomes for the medication standard are poor. Service users abilities to self-administer medication are not sufficiently assessed or known. From discussion and sight of the Community Care Assessment it is thought that one service user may be able to self-administer and that he may have done so prior to admission to the home. Senior staff feel that he is becoming deskilled because staff administer medication to him but were unable to explain why staff undertake this task. It was later reported that this person had self administered medication in the community and was discharged from hospital to 24 hour support at the request of the Consultant Psychiatrist to ensure a period of medication administration could be monitored. Furthermore permission for staff to administer medication to this and other service users has not been sought or obtained. Following the inspection the Consultant Psychiatrist liaised with CSCI in relation to the capacity of the people accommodated and in his professional opinion reported that only one individual is able to consent to medication due to the nature of people’s disabilities. Systems are also not sufficiently in place to account for a further service users medication being disguised. This compromises the service users rights and the safety of those around. For example a letter of authorisation from the GP was not available at the time of inspection to demonstrate that this covert method of administration is in the service users best interest. Following the inspection the provider later informed CSCI that a letter was available on file but not produced by staff on the day of the inspection. A letter was faxed to Commission For Social Care Inspection on 04.10.06 stating that the person is not able to give informed consent and greatly benefits from the effect of the prescribed medication. This should be discussed and agreed at multidisciplinary review. A care plan outlining protocols for covert administration is not sufficient referring only to ‘disguised in food as advised by GP’. Discussion highlighted further concern as Inspectors learned that tablets are disguised in a variety of different foods. A pharmacist has not been consulted to verify the stability of the medication in the various substances used as disguise. Furthermore a risk assessment is not in place to ensure the stability of the product and that others are protected from edible products containing medication e.g. sandwiches and chocolate. Care records in respect of medication are duplicated increasing the risk of error as a result of not updating all copies available. Failure to update all copies provides the potential for errors in administration of medication. For example one file is held that details prescribed medication for all service users. This is used to check deliveries of medication and is generally viewed as the up to date copy. The medication profile on a service users care plan was assessed and this had not been updated to include amendments to medication providing the potential for under medication if staff had referred to this copy. Furthermore photographs of service users were not available on medication Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 18 administration signature sheets on medication cassettes, which again provides the potential for errors in the administration of medication. A list of signatories held for those staff accredited to administer medication was not available. Medication Administration Records were available but until the end of August these had been handwritten by staff rather than typed by the dispensing pharmacist for the service user case tracked. This increases the risk of human error and handwritten directions were not sufficiently detailed to reduce this risk, for example they have not been signed by two staff to confirm accuracy, quantities received were not recorded and there was insufficient detail to accurately guide administration as prescribed e.g. instructions to ‘swallow tablets whole and not to chew’ were omitted. Gaps in administration records for the service user case tracked were also evidenced. There was no evidence that these possible omissions in administration of prescribed medicines to the service user had been investigated and no evidence that medical advice had been sought as a consequence placing the service user’s health at potential risk. From discussion it was thought that the one omission was as a result of there being an inadequate medication stock which is unacceptable. Other omissions could not be accounted for. There is no evidence of there being a sufficient medication audit system so errors can be picked up without delay, investigated and appropriate action taken to protect the service users interests. Neither is there a system for the management to assess staffs’ ongoing competency to administer medication correctly. Medication storage was assessed and the cupboard is not overstocked and out of date medications have been returned to the pharmacist, this representing an improvement since the last inspection. A medical fridge is available. Fortunately however it contains no supplies currently as temperature records indicate unacceptable readings of minus 4 degrees, which would have seriously compromised any medication stored. Action had not been taken in response to the identification of these temperatures. Improvements are also required in respect of ordering medication. Guidance for this is within the homes medication policy but practice does not comply. For example orders for repeat prescriptions are being sent direct to the chemist rather than to the GP and are being returned directly from the GP to the chemist. This is poor practice as it does not allow the home to copy and check prescriptions to ensure that they tally with that ordered by the home. The home no longer receives quarterly support visits from the supplying pharmacist due to changes in the funding arrangements for this. Senior staff said they must now apply to the PCT for this service which given the outcomes from this inspection is advised. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 19 No service users are diabetic, no controlled drugs are held and at the time of inspection no one was taking a short course of medication. Additionally the service user case tracked is not prescribed any ‘as required’ medication so these aspects of practice were not assessed. Time did not allow for the observation of medication administration so these areas will all be assessed at subsequent inspections. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 20 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): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their representatives have access to a complaints procedure that enables their views to be listened to and acted upon. Procedures to safeguard service users from potential abuse are in place. EVIDENCE: The home has a complaints procedure in place and designated key workers have a responsibility to voice concerns or complaints made by service users. Minutes of a residents meeting held on 2.8.06 evidence that people are aware of the complaints procedure. An independent advocacy service is also available in addition to regular residents meetings held. Since the last inspection the home has received two complaints however the one was in relation to another residential establishment and the complaint was reported to the manager of the home concerned. The other complaint recorded was in relation to a service user complaining about another service user. It was reported that this had been passed onto the service manager to deal with however the outcome was not known. No complaints have been referred to the CSCI since the last inspection. Two compliments were seen from the families of two service users thanking staff for the recent barbeque event held and for the happy afternoon shared. A condition of registration was previously imposed for the manager to attend Protection of Vulnerable Adults training. The manager has since undertaken this training and a copy of the certificate was forwarded to Commission For Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 21 Social Care Inspection. It was reported that all but nine staff have attended training in the local adult protection policy and procedure. Service users are supported to manage their finances and records of transactions maintained. Inspectors were unable to access the petty cash fund and service users bank account documentation due to the manager being on annual leave and therefore not accessible. The CSCI were later informed that the home holds an imprest cash fund in the safe and this is accessible to senior staff along with service user’s individual cash bags and the comforts fund cash tin. The service user’s bank statements are accessible via the Registered Manager or Service Co-ordinator, Senior staff support individuals to open bank statements and pass them to the Manager for reconciliation and filing. The finances of two people were checked against records held. A personal allowance record is held for each individual and systems are in place to monitor finances on a daily basis. The cash balance for one individual was £3.00 short of the records held which was identified by the two waking night staff who are responsible for undertaking daily checks and recording the findings on a financial reconciliation sheet. The finances for the other person were an accurate reflection of the records held. Financial records also evidenced a further service user finances being £40.00 over. It was later reported that these amounts were reconciled and the only delay was due to the inspection. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 22 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, 27 and 30 Quality in this outcome area is adequate. 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: Both inspectors, accompanied by an assistant manager, undertook an environmental tour of the home. A new pathway from the fire exit to the perimeter fence is now in place providing greater access to the adjacent ‘Aquamira’ facility. The home is unitised providing three flats known as Sabrina, Kingfisher and Primrose. Each flat comprises of a lounge, kitchenette and dining area. A number of rooms throughout the home have been redecorated since the last inspection and fitted with new curtains and carpets and that the service users had an active involvement in choosing the colour schemes. It was reported that new three piece suites have been purchased for each flat. The bedrooms viewed were clearly personalised and well presented. En-suite facilities are not provided however each room has a vanity unit. Bathroom and shower facilities are provided throughout the home however these facilities are looking tired and cold in appearance and are in need of investment as they continue Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 23 not to provide people with a pleasant room to bathe as identified at the previous inspection. For example one bathroom in Primrose is fitted with an odd coloured suite and broken and missing tiles were seen in a further bathroom. Water temperatures are tested and recorded by staff on a daily basis and a review of these records evidence that bath water temperatures average 34°C. Water temperatures tested by inspectors at sink outlets exceeded 50°C and the assistant manager was advised to take immediate action to safeguard service users from a risk of scalding. Following the inspection CSCI received confirmation from the home and the Property and Maintenance Department that thermostatic valves have since been fitted to all hot water outlets in rooms accessed by service users. It was reported that although the home has an allocated budget provided for repairs and renewal, a written planned maintenance and renewal programme has not been developed. The home was found clean and tidy throughout during this unannounced inspection. Systems to control the spread of infection require review for example several unnamed bathmats were found on top of one another in bathrooms and some clearly in need of replacement and the storage of such needs review. The laundry was inspected and the premises were generally acceptable with protective clothing, soap and paper towels readily available. Sluicing facilities are available within industrial machines. One washing machine was out of order on the day of the inspection however this had been reported to maintenance. Clean laundry was found to be stored in the laundry and in such a small environment poses a cross contamination risk. Clinical waste bins are lockable. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 24 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): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a committed, trained and enthusiastic staff team and are safeguarded by the homes recruitment procedures. EVIDENCE: Discussions held with two staff on duty evidence they are knowledgeable and have a good understanding of the individuals whom they support. Staff were observed to be accessible, good communicators and interacted appropriately with the service users present during the inspection. The main staff files are retained at the Personnel Department at Shirehall. The files of the people recruited since the last inspection was reviewed by appointment at the Shirehall on 13th July 2006. All files were presented to an excellent standard and contained all the relevant information as required by the Care Homes Regulations. Staff files containing confidential information are held in the homes filing cabinet accessible by the Registered Manager and Service Co-ordinator and were not inspected on this visit. Training available to one staff member employed for just in excess of 12 months was case tracked. Records evidence that she has been supported to undertake most training courses during the period of her employment at Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 25 Kempsfield including Dealing with Difficult Situations, Food Hygiene, Infection control, Health and Safety, Moving and Handling, the Safe Administration of Medication (accredited), Adult Protection, the administration of rectal and oral medication for epilepsy to meet the needs of an identified service user, Key working, Risk Assessment Awareness, COSHH and First Aid Appointed persons (which expires this month). She had obtained an NVQ in Care prior to appointment. Courses outstanding for this staff member include Physical intervention / Challenging Behaviour management and it was of concern that Fire training could not be evidenced during her employment at Kempsfield (previous certificates were available for 1997 and 2002). Senior staff believe that she undertook Fire training in 2005 but there was no certification available to provide evidence of this. Discussion with a staff member showed that training provided is valued and useful. Discussion with this staff member also showed a positive and motivated approach. Questioning showed she has a good understanding of the needs (personal care, eating support needs, family contact, cultural, behavioural) of a service user to whom she is key worker. The home does not employ anybody currently who is under 18 or 21 years old. The records of three other new staff were assessed and are undertaking induction to LDAF standard but this has not been completed within the mandatory time schedule following appointment. The home has however exceeded the 50 target for care staff qualified to NVQ level 2 Standard. Training records for individual staff members have been improved. Senior staff are aware of the need to introduce a team training matrix to readily identify training completed and required. This will better support the management of training programmes. Discussion with a staff member showed she was satisfied with supervision arrangements describing supervision as very regular. Assessment of supervision records showed previous dissatisfaction with the regularity of supervision between December 2005 and April 2006 where the staff member had requested supervision. Records show some limited subsequent improvement from April until June 06 with supervision not having been provided since. Records prior to December 05 were not available however to assess the frequency of supervisions over a full 12 month period. The Inspector was told that supervisions should be held 6 weekly, records available show this staff member to have been provided with 3 supervisions within a ten month period from December 05. Discussion with staff showed an understanding of the function of supervision however and that there is clearly a culture of supervision for staff embedded within the home. A second staff member was fulsome in praise for how she had been supported during her time employed at the home. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 26 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): 37,38,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management approach of the home creates an open and positive atmosphere from which the service users benefit. Quality assurance systems require further development to ensure all aspects are performance is reviewed. The health, safety and welfare of service users and staff is not fully promoted. EVIDENCE: The Manager who is the Registered Manager has completed her Registered Manager’s Award and the Inspector was told is working towards her required NVQ 4 in Care qualification. There was evidence that she has attended some additional training courses this year to update her knowledge and skills e.g. disciplinary, Health and Safety and First Aid. The Assistant Manager said that she is aware that the Manager receives supervision but in the absence of the Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 27 Manager on the day of inspection records were not accessible to evidence the frequency of supervisions provided to her. The Manager’s line manager undertakes regulation 26 monitoring visits to the home and detailed records evidencing a focus upon service user views and experiences were available on the premises to evidence these although there was no evidence of visits for July, August and September 2006 however a copy of reports are forwarded to CSCI on a monthly basis. Registration certificates are appropriately displayed within the home. Full staff meetings are held and minutes evidence free and open discussion amongst staff members where service user opinions are represented. The frequency of meetings from records available indicates that fewer meetings have been held in 2006 than in 2005. ‘Flat’ meetings are also held but again there is not a consistent pattern to the frequency of meetings with Kingfisher staff having met twice in 2006 (June and August 06) but Primrose ‘flat’ staff not having met at all in 2006 and only once in 2004 and once in 2005. Service users meetings are held and pictorial minutes are available. There is evidence of an independent facilitator leading one meeting and this is good practice. There is also evidence that service user views expressed in such meetings are acted upon. For example minutes state ‘X would like to go to Blackpool’. Discussion with this service user showed that she is going to Blackpool and this was confirmed with a staff member who was able to confirm the date for the visit. All staff members spoken to spoke very highly of the Manager and the Management team in general. A senior staff member said that the manager is ‘absolutely fantastic’ and that there is ‘a great relationship between the staff and the manager’, that she is ‘always approachable and gives time’ and that Kempfield is ‘a very happy home’. It was added that the Manager likes things to be done correctly, that the service users come first and that she always says thank you and well done to staff, which is very motivating. A further staff member said that worries can always be discussed with the manager and that the manager always takes action. The staff member confirmed that the manager is approachable and available and that whilst ‘she praises us a lot’ she also tells us how we need to improve. A third staff member said ‘the managers have been great for my confidence… I don’t feel silly asking for advice’. In response to the question what does the home do well the staff member replied ‘everything and I’m not just saying that. Support is there 24 / 7 for little and big things. We help the service users to access the community – theatre, shopping, holidays etc’ There is evidence of some quality monitoring within the service. The management team monitors maintenance systems and care files monthly. However the effectiveness of this is questioned given outcomes from this inspection discussed earlier in this report. Annual development plans are Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 28 available for 2004 / 2005 and 2005 / 2006 but not for 2006 / 2007. There is evidence that staff and resident meetings are service user focussed and include resident opinions which are acted upon however these are not reliably frequent and may only represent the vocal few. Anonymous user satisfaction questionnaires are not currently used but are planned to gain feedback from service users, relatives and other stakeholders. A Fire Officer inspection was last carried out in April 2005. Fire alarm systems are well maintained and regularly checked. Fire drills are carried out and include service users. Fire training is not well evidenced for a staff member case tracked and must be reviewed. Although a recent fire risk assessment is in place control measures are not included for all hazards identified and night staff smoking in the building at night is not included or considered as a possible hazard. Evacuation risk assessments have recently been undertaken in respect of individual service users but do not consider a range of significant variables such as action to take in respect of those service users who are wheelchair dependent. Food hygiene standards were inspected in January 2006 by the Environmental Health Department and ‘very good standards of compliance’ were found. One recommendation was issued which has been met. As previously stated water temperatures were found to be unacceptably hot at basins in bedrooms and bathrooms and posed a scalding risk to service users. Senior staff took immediate action to make the situation safe by contacting the Property and Maintenance Department and locking rooms to prevent risk to service users during the evening. From observation this caused some upset to service users and a quicker response from property maintenance would have prevented this. Furthermore it is not clear if unguarded radiators throughout the home that blow hot air are low surface and risk assessments have not been carried out. Fridge temperatures were found to be unacceptably high for the whole of week beginning 11th September. Whilst these were corrected the following week (following a fridge engineer visit that could not be evidenced) there is no evidence of action taken to prevent risk to service users from food borne illness. Staff report that the fridge in question is old and is subject to frequent fluctuations in temperature which is a health risk. A five-year electric total installation certificate to evidence the safety of electrical hard wiring throughout the property could not be provided on the day of the inspection however a copy of this was forwarded to CSCI on 04.10.06 However the Gas Landlord certificate for the boiler which expired in August 2005 (this was available for gas kitchen appliances dated April 2006) was not available however managers have since requested a copy from maintenance department. Portable electric appliances have been recently tested for safety. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 29 There are several well-stocked first aid boxes throughout the property and staff were aware of their location. Fifteen of the staff team have attended a one day first aider course and are ‘appointed’ first aiders. All Senior staff and Night Care staff (11 in total) have attended a four day course and hold First Aid at Work Certificates. New bedrails (built into the bed) have been provided for the three service users who require them since the last inspection and this represents an improvement better protecting service users safety. Risk assessments have been carried out that account for maintenance of the rails and the need for their use. A risk assessment is in place for the security of the premises and all windows are fitted with window restrictors. Wardrobes are not restricted to prevent the risk of toppling and risk assessments are not in place to account for this decision. Whilst there are no written contingency plans in the event of an emergency, discussion with senior staff showed that staff are clearly versed in action to take in the event of the premises not being occupied at short notice during the night for example. Hazardous chemicals are generally well managed but this unannounced inspection found two omissions which posed risk to service users. A pressurised air freshener canister was found unattended in a bathroom and a bucket containing an air freshener and multi surface cleaner that had been decanted into the empty spray container for a different product and left by domestic staff in a service users bedroom. COSHH assessments were inspected and were in place for the air freshener but not for the particular multi surface cleaner found in the bedroom. The range and quality of risk assessments requires review and senior staff acknowledged this. As previously stated a manual handling assessment for someone who is wheelchair dependent stated ‘may require two staff sometimes’ and the weight or height of the person was not stated. Some of the previous requirements for improvement have been met. However it is disappointing that those posing significant risk to service users have not e.g. water outlet temperature monitoring and the review of COSHH assessments which had been started but not completed the day prior to inspection. It was later reported that COSHH assessments had been reviewed on 8/2/06 and 11/6/06 and the Assistant Manager had commenced a third review on 2/10/06 and copies had not been put on all flats. This inspection has also seen performance in relation to medication judged to be poor and the number of requirements issued for improvement significantly increase overall to ensure that the home meets the National Minimum Standards. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 30 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 x 4 x 5 2 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 2 25 x 26 x 27 2 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 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 1 x 3 3 2 x x 1 x Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 31 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 YA1 Regulation 4(1)(c) Timescale for action The Statement of Purpose 01/12/06 must include the criteria for admission to the home, including the homes policy and procedures for emergency admissions. Contacts must be an 01/12/06 accurate reflection of the placement provided and include all elements of National Minimum Standard 5.2 and service users be supported by representatives if required in drawing up the contract. Support plans must be 20/11/06 drawn up from initial assessments and be reviewed with the service user and significant others at least every six months and updated to reflect any changing needs. A reactive management 06/11/06 plan must be developed for people whose needs require it and linked to DS0000032578.V296554.R01.S.doc Version 5.2 Page 32 Requirement 2 YA5 5 (c) 3 YA6 15 (2) 4 YA6 15(1) Kempsfield the service user plan. 5 YA9 13(4) Risk management strategies must be developed for identified risks to service users and control measures clearly recorded and reviewed. Service users abilities in respect of the administration of medication must be assessed. Care plans based upon risk assessment must indicate in detail how medication is to be administered and where service users are assessed as able to selfadminister their medication, this must be encouraged within a risk management framework. Medication administered covertly must be subject to written approval from the multidisciplinary healthcare team, which includes the resident’s GP. The pharmacist must be contacted to ensure that the practice developed does not compromise the viability of the medication and care plans must explicitly outline in detail protocols for the administration of covert medication based upon risk assessment that is made known to all staff. Service users (or their representatives) consent to the administration of medication by staff must be obtained and recorded in the individual plan. DS0000032578.V296554.R01.S.doc 06/11/06 6 YA20 13(2) 20/11/06 7 YA20 13(2) 20/11/06 8 YA20 13(2) 20/11/06 Kempsfield Version 5.2 Page 33 9 YA20 13(2) 10 YA20 13(2) 11 YA20 13(2) 12 YA20 13(2) 13 14 YA20 YA20 13(2) 13(2) 15 Kempsfield YA20 37(1)(e) Medication profiles in care plans must be reviewed and must be kept up to date for all service users. Photographs of service users for the purposes of identification must be held on their medication administration records. A list of signatories for all staff authorised to administer medication must be held. All handwritten entries on MAR sheets must be completed in full and must include start date, name of medication, strength, quantity, times of administration, who prescribed by, must contain sufficient direction as per prescription, must be signed and verified by two staff. Where medication is prescribed ‘as directed’ the home must seek written medical clarification and ensure this is included in the prescription. The home must review its practice in relation to ordering medication. The Manager must introduce a formal system to audit medication administration records to ensure that service users receive their medication as prescribed and potential errors are noted, investigated and acted upon without delay. All errors and omissions DS0000032578.V296554.R01.S.doc 06/11/06 06/11/06 06/11/06 06/11/06 06/11/06 06/11/06 16/10/06 Page 34 Version 5.2 13(2) 16 YA20 13(2) 17 YA20 13(2) 18 YA24 23 19 YA27 13.4.a 20 21 YA30 YA39 13(4)(a) 24 in medication must be reported as Regulation 37 to CSCI. A system to assess staff’s ongoing competency to administer medication must be developed and implemented. The temperature of the medication fridge must be maintained between 2 and 8 degrees centigrade by daily monitoring of the maximum and minimum temperatures and action must be taken and evidenced where temperatures do not comply. A planned written maintenance and renewal programme for the fabric and decoration of the premises must be developed and include the refurbishment of the bathrooms and the replacement of the old fridge. The home is required to ensure that all hot water outlets are controlled to provide hot water close to 43°C (previous timescale of 28/11/05 not met). The manager must review infection control procedures. The manager must review the quality assurance system based upon seeking feedback from service users, family, friends and other stakeholders. The results of which should be published and made available to interested DS0000032578.V296554.R01.S.doc 20/11/06 16/10/06 20/11/06 09/10/06 13/11/06 01/12/06 Kempsfield Version 5.2 Page 35 parties. 22 YA42 13(4)(5) The manager must review the range and quality of risk assessments for example manual handling risk assessments must be detailed with evidence of review. Fire training must be provided at the required frequency for all staff and must be evidenced. The manager must review the fire risk assessment seeking advice of the Fire Service ensuring all hazards are included with control measures for all risks identified. All hazardous chemicals must be attended at all times or must be locked away when not in use. A risk assessment in respect of radiator surface temperature must be undertaken. Fridge temperatures must be maintained within safe ranges at all times. Where temperatures do not comply the home is required to ensure that temperature monitoring is effectively linked to action with evidence and standards maintained. The home is required to ensure that all hot water outlet temperature monitoring is effectively linked to action and standards maintained (Previous timescale of 28/11/06 not met) 16/10/06 23 YA42 23(4)(d) 20/11/06 24 YA42 23(4) 13/11/06 25 YA42 13(4)(a) 16/10/06 26 YA42 13(4)(a) 06/11/06 27 YA42 13(4)(c) 16/10/06 28 YA42 13(4)(a) 09/10/06 Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 36 29 YA42 13(4)(a) The manager must provide a copy of an up to date gas Landlord certificate for the homes boiler to CSCI. 06/11/06 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 3 4 5 Refer to Standard YA6 YA19 YA35 YA36 YA42 Good Practice Recommendations It is recommended that a person centred plan (PCP) be developed with each service user as soon as possible. It is recommended that a health action plan be developed with each service user as soon as possible. It is recommended that a team-training matrix be developed to help to identify omissions in training. It is recommended that the manager review the frequency of staff meetings. It is recommended that all freestanding wardrobes be secured to prevent the risk of toppling or risk assessments be carried out to account for any decision not to comply with this. Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. Extracts may not be used or reproduced without the express permission of CSCI Kempsfield DS0000032578.V296554.R01.S.doc Version 5.2 Page 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!