Inspection on 31/10/05 for Kempsfield

This inspection was carried out on 31st October 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kempsfield 10/07/07

Kempsfield 03/10/06

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 Terry Woods Announced Inspection 31st October 2005 09:30 Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 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.V261674.R01.S.doc Version 5.0 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. 11th July 2005 Date of last inspection Brief Description of the Service: Kempsfield is a care home registered with the Commission for Social Care Inspection to provide accommodation and personal care for up to nineteen Adults with Learning Disabilities, who are aged under or over the age of 65 in any proportions. The home is operated by Shropshire County Council Social Services Department. Ms Debora Mowl, the manager, is responsible for the Home’s day-today management. Kempsfield is located on the edge of Sutton Park, a private residential estate in Shrewsbury. The home is a two storey building and has been converted into three long-term ‘flat’ type units. The home has a lift installed although the first floor accommodation is limited to service users who are more ambulant. 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 needs. Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Inspection work undertaken by CSCI is proportionate in relation to how a home has performed in the past and Kempsfield has a consistent history of providing a good service for the people in residence. This inspection therefore focused mainly on the “key” standards. The inspection was carried out throughout the day over a seven-hour period and involved the study of a range of records and a tour of the building. A number of the service users were at home at the time receiving day care at Kempsfield. The remainder returned from the community later in the afternoon. A number of the service users and staff were spoken with during the course of the inspection. The registered manager was not on duty on the day of the inspection. One of the assistant managers was in charge of the home and the service manager provided support for the inspection process. What the service does well: What has improved since the last inspection? What they could do better: The home strives hard to meet the needs and improve the facilities for the people in residence, however, more attention to detail concerning safety aspects around the home as identified in the report is clearly needed Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 6 The environment also requires improving particularly to some of the bathing areas. The ‘Sabrina’ bathroom is looking ‘tired’ in its appearance and maintenance and a refurbishment programme to bring the facility up to an acceptable standard would be beneficial to residents. A bath and shower room in ‘Primrose’ although serviceable is also below standard in its appearance. 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.V261674.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 The home has an effective needs assessment procedure Service users do not receive adequate information about their placement as would be set out in a statement of terms and conditions document. EVIDENCE: The service user group at Kempsfield remains stable with recent admissions coming from nearby Eskdale House to provide a more appropriate service for those individuals. Records show that an assessment of need is carried out with all residents prior to admission and used to inform the individual’s care plan. The home has not yet 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. Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10 The service user plans are comprehensive and updated at appropriate intervals ensuring that the individuals’ needs are met. Where possible service users are consulted and do make decisions about their lives. EVIDENCE: All residents have an individual life plan, compiled on admission, which supports the assessment of need. Good support plans are in place, which are well written and reflect service user involvement. Individual risk assessments including moving and handling techniques are also within the individual plans and these are regularly reviewed protecting the safety of the individual concerned. It is however noted that the files which are kept in service users flats are getting very ‘full’ and require attention if they are to continue to be an effective working document Service users were observed being encouraged to make decisions for themselves, as much as they were able, about how they would spend their time and in contributing towards the preparation for a halloween evening that day. Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 10 Service users are also supported to hold regular meetings. Minutes are taken and a sample read confirmed discussions being held around issues concerning the service users. Examples are ‘flat’ life, holidays, meals and privacy. Parking issues were also discussed, as was the installation of a water dispenser. A group of residents requested that the conservatory be cleared of stored items to enable them to use this facility to shelter whilst waiting for their transport to arrive. Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Good use is made of the community to support and enrich service users’ work experiences, leisure and educational opportunities. Service users are provided with choice and variety of meals to promote a healthy and balanced diet. EVIDENCE: The home is maintaining good levels of leisure and social activity for service users. A small in-house daytime service has been formed using 5 staff from the recently closed Monkmoor Centre. This has created the opportunity to provide fully organised community activities for service users to access directly from home rather than attending a ‘centre’. A staff member interviewed reported that the service is running well and benefiting the residents at Kempsfield. One service user returned from a shopping trip and was clearly happy with the arrangement. Diary charts are posted in service users’ bedrooms giving prompts for their weekly activities. Another service user reflected on her recent holiday to Cardiff and reported that she had a ‘lovely time’ and that the weather was nice and sunny. A staff member confirmed the appropriateness of the hotel for the two holidaying Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 12 wheelchair users who were supported throughout the week. Other holidays reported on included visits to Blackpool and the Isle of Wight. Another service user reflected on a trip to a theatre in Wolverhampton where after watching a show she stayed overnight in an Hotel. She was clearly pleased with the excursion and said that she had a meal and a really nice time. There were no family visitors on the day however records suggest that there is some activity in this area and a room is available for relatives to stay overnight if required. Meals are provided from a central kitchen and transported to each ‘flat’ area in modern heated trolleys. Service users reported that the meals were good and the cook confirmed that choices are given to meet their preferences. She also reported that the home is taking part in a healthy eating programme, which is supported and assessed by the local Environmental Health Officer. The menu is over a three-week rota and residents are consulted about meals through their regular meetings. Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 There is a clear and consistent health care planning system in place to adequately provide staff with the information required to satisfactorily meet residents’ needs. The process employed for recording the administration of medication is good but further attention to detail is required to avoid the potential to place residents at risk. EVIDENCE: Very good health monitoring notes were seen concerning one service user following a recent operation. Arrangements were made in consultation with the Commission for Social Care Inspection to temporarily accommodate this service user on the ground floor due to his mobility difficulties and to aid his recovery Three service users have planned attendance at the adjacent ‘Aquamira’ facility and the use of the hydrotherapy pool as a part of their overall service. One service user has complex moving and handling needs and as a result has been provided with three types of hoist to enable a variety of tasks to be carried out in safety. One resident was finding it uncomfortable to speak due to a chest infection, which had recently occurred. Case files showed good noted being kept with a reference to the prescription of antibiotics by her GP. Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 14 Each unit was seen to have it’s own medication store and sample records seen were in order. Controlled Drugs are stored centrally in an appropriate cabinet and medication that requires refrigeration is kept in a dedicated refrigerator in the office. Senior staff were observed monitoring medication that is not administered through the blister pack system. Despite this it is noted that there are bottles of tablets being retained at the home that are well out of date and must be returned to the pharmacy. At least two bottles had dates of 2002 and 2003 with one prescribing 56 tablets to be taken 1 twice daily. Both service users concerned are still in residence. Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The service users are protected from abuse and the staff enable their views to be taken into account despite the nature of their disabilities. EVIDENCE: The home has received no complaints since the last inspection. The home has a copy of the local policies and procedures for the protection of vulnerable adults as well as a copy of their own complaints procedure. These are part of systems in place that ensure that the service users are listened to and protected from abuse, neglect and self-harm. The level of the disabilities of some of the service users means that they are unlikely to be able to access these formal policies. Observation of the staff however, interacting with service users and communicating between them, indicated that they would be aware of any dissatisfaction expressed by a service user. A whistle blowing policy is available to be used. A condition of registration to attend for POVA training imposed on the recently registered manager has not yet been completed. The diary however showed that a course has been applied for on 06/09/05. Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 29 & 30 The standard of the environment is good providing service users with an attractive and homely place to live. EVIDENCE: Kempsfield is situated in the southern part of Shrewsbury and was purpose built as a hostel some years ago. Since then it has evolved to meet the needs of those now living there with a variety of adaptations having been made to the structure of the buildings. Progress continues to be made towards making the grounds more secure in terms of safety for the residents. Work was in progress to lay a new pathway from the fire exit to the perimeter fence providing access to the adjacent ‘Aquamira’ facility. The home has a number of bathrooms that offer a choice of showers or baths with a variety of aids being available in each including a hoist operated tracking across the ceiling. A downstairs bathroom however, identified on the day, has no / or faulty hot water controls at the bath and sink. A second bathroom had unacceptable daily temperatures recorded ranging from 34°C to 39°C. The ‘Sabrina’ bathroom is looking ‘tired’ in its appearance, and there are broken tiles around the bath and one missing at the sink. A bath and shower Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 17 room in ‘Primrose’ although serviceable is also below standard in its appearance. With the above exceptions, a tour of the home confirmed a clean, hygienic and pleasant environment for service users to live. Service users rooms are well laid out and clearly personalised to each individuals’ needs. Aids and adaptations are fitted wherever required. For example one service user has a hoist with overhead tracking to comfortably move from his bed to his sitting area or wheelchair. A number of bedsides are in use throughout the home. Two have been purchased privately and are an integral part of the bed and fully functional and safe. Others however are provided by the County’s Loan Store and were found to be unstable or inappropriately fitted. Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35 & 36 There is an effective and well-supported staff group with the skills and knowledge to enable service users to enjoy a quality of life that meets their individual requirements and aspirations EVIDENCE: The rota showed that the staff are working at times and in sufficient numbers to meet the needs of the service users. A high proportion of the home’s staff have achieved NVQ level 2 or above in care. Formal staff supervision has been reorganised and reported as in the process of ’settling down’. This will enable staff to formally keep up to date with good practice, changes in procedures and matters around the care for individual service users. A supervision checklist was seen and all senior staff have supervisory responsibilities, four of whom have completed a supervision skills course. A copy of the training plan and matrix was provided and together with feedback from staff demonstrated an effective policy. A new staff member talked through the induction process and of the home’s policy to ensure that all new recruits complete they’re mandatory training at this time. This includes food hygiene, lone working, moving and handling and fire safety. Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 & 43 There are satisfactory systems in place to monitor the service provided at the home with genuine service user involvement. The systems in place to ensure that service users’ health, safety and welfare are promoted and protected are in need of review in the areas identified. EVIDENCE: Quality assurance feedback is sought from service users through meetings and the ‘taking part’ movement. It was reported that the home is experiencing some clear success with this process where service users are actively consulted on home policy issues. Observations also confirm that service users are assisted by staff to feel comfortable about disclosing their feelings, which due to their disability often does not come naturally. Staff were seen actively taking service users through the process of putting forward their opinions and developing confidence whilst setting out an area for a Halloween party that evening. An identified ‘service manager’ makes regular ‘Registered Provider’ visits to Kempsfield and provides a written monthly report, copied to the Commission Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 20 for Social Care Inspection. These are very informative and service user focused. There were records kept in the home that showed safety issues such as hot water temperature controls and fire procedures are monitored regularly. It is noted however that the hot water temperature records are not effectively linked to ‘action’ where it is identified that standards are not being maintained. (See standard 27). The home also has a full risk assessment process kept in the individuals’ files for personal issues and centrally in the office for the more general issues. COSHH risk assessments however, although good, have not been reviewed in the last six years. There are no risk assessments in place with regard to the use of bedsides. Policies and procedures continue to be an area of constant review to ensure that Shropshire County Council documentation is relevant to the home’s unique function Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X 2 X 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 3 14 4 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 4 X X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kempsfield Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X 3 2 3 DS0000032578.V261674.R01.S.doc Version 5.0 Page 22 NO 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 YA10 Regulation 17.1.a 17.3 Requirement Service user files which are kept in the flats are very ‘full’ and require attention to continue to be an effective working document The home is required to return all ‘out of date’ medication to the pharmacy The home is required to ensure that all bedsides used are stable and appropriately fitted and maintained by trained staff The home is required to ensure that all hot water outlets are controlled to provide hot water close to 43°C The home is required to ensure that all hot water outlet temperature monitoring is effectively linked to action and standards maintained The home is required to replace broken and missing tiles in the ‘Sabrina’ bathroom The home is required to produce risk assessments with regard to the use of bedsides. The home is required to review the COSHH risk assessments Timescale for action 23/01/06 2 3 YA20 YA24 13.2 13.4.a.c 28/11/05 28/11/05 4 YA27 13.4.a 28/11/05 5 YA27 13.4.a 28/11/05 6 7 8 YA27 YA42 YA42 23.2.b.d 13.4.c 13.4.c 23/01/06 28/11/05 26/12/05 Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kempsfield DS0000032578.V261674.R01.S.doc Version 5.0 Page 24 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. 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