Inspection on 27/06/06 for Kendall House

This inspection was carried out on 27th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kendall House 02/11/05

Kendall House 29/06/05

Kendall House 23/02/05

Kendall House 03/11/04

Kendall House 23/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Kendall House 15 Wesley Lane Warmley South Glos BS30 8BU Lead Inspector Paula Cordell Key Unannounced Inspection 27 & 28th June 2006 09:30 th Kendall House DS0000003370.V301814.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 Kendall House DS0000003370.V301814.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. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kendall House Address 15 Wesley Lane Warmley South Glos BS30 8BU 0117 9602508 0117 9566050 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) Mrs Marilyn Joan Clarke Mrs Julie Ann Smith Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 8 persons aged 18 - 64 years requiring personal care only May accommodate one named person with learning disabilities who has dementia 2nd November 2005 Date of last inspection Brief Description of the Service: Kendall House is located in the village of Warmley approximately five miles from the centre of Bristol. It is in a semi rural location close to Warmley Common. There are shops and other community amenities within a mile of the home. The home is registered with the Commission for Social Care Inspection to provide accommodation and personal care to eight persons with learning disabilities aged between 18 and 64 years. Kendall House is one of four homes within the Manor House Organisation that provide for adults with learning disabilities and one provides respite for children with a learning disability. The accommodation in Kendall House is on two floors. There is one shared bedroom. There is a spacious patio area accessed from the lounge area, which leads to the garden. The service values for the home are concerned with dignity, independence, and participation, valuing people, equality, rights and working together. The fees for the service range from £550 to £1200. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection. The purpose of the visit was to monitor the progress to meet the requirements and recommendations from the last unannounced site visit in November 2005 and review the standard of care provided to the residents at Kendall House. There has been no inspection activity between November 2005 and this site visit. The focus of the site visit was on the general care of a sample group of residents and the environment, including an extensive tour of the premises. This provided a good opportunity to observe residents as well as allowing for informal conversations with individuals and the staff supporting them. Three members of staff were spoken with during the inspection, in addition to the registered manager. The home has been sending information in respect of regulation 37 notices of events affecting the well being of the residents and monthly provider reports in respect of regulation 26 of the Care Homes Regulations. These were used as a focus for the site visit along with the pre-inspection questionnaire completed by the home and survey forms received from relatives (5) and residents (6). The site visit was conducted over a period of 7 hours over a two-day period. This enabled the inspector to meet with 6 of the 8 residents and the manager who was available on the second day of the inspection due to a training course. What the service does well: Kendall house provides residents with a homely environment. The organisation has supported residents with a learning disability for many years. A number of residents have lived in the home since it opened. Residents lead active and individual lifestyles, making full use of the community. There are good quality assurance systems in place ensuring the smooth running of the care home. There is a strong commitment to ensuring that competent staff support the residents. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents had sufficient information to enable them to make a decision to move to the home. Residents’ care needs are continually assessed and updated to meet the individuals’ changing needs. EVIDENCE: The home has a statement of purpose and a service user guide. This has been reviewed and amended since the last inspection. This is good practice. Both documents met the National Minimum Standards. Consideration could be given to making these available in different formats if relevant. Residents care needs were being assessed and updated demonstrating that the changing needs of the individuals living in the home were being met. Copies of placing authority’s assessments and care plans were in place and these were built on by the home for each individual. There were clear procedures for the home to follow on the process of admission. The home has an established group of residents and the last person to move to the home was in 1999. The home offers a trial period and visits leading up to a permanent place being offered ensuring all parties are happy with the service provided. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 9 Since the last inspection the home has submitted an application to include one individual with dementia to the conditions of registration. The new certificate was displayed in a prominent place in the home. All staff have received basic training on dementia, with one member of staff completing a distance learning pack. This is good practice. A member of staff stated that the plan is for all staff to complete the distance learning pack. Staff on duty demonstrated through conversation and observation a good understanding of the care needs of the individuals living in the home and how to meet them. Resident’s contracts were seen at the last inspection and were found to meet the requirements of the Care Homes Regulations. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Kendall House provides individual tailored packages of care to residents. Residents are involved in the planning of their care and are supported to take risks as part of an independent lifestyle. EVIDENCE: Three care plans were examined in detail during this site visit. Each person had a plan of care, which included skills development. These provided sufficient detail on how the staff should support each person to meet their care needs and achieve their personal goals. Information was person centred. Plans included how the person wanted to be assisted, how often, what the person did not like and risks that required assessment to ensure the individuals safety and protection. The home in response to a recommendation has reviewed care documentation to ensure that it is relevant and archived some information. Files seen were logical and easy to negotiate. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 11 Care plans and risk assessments were being reviewed in accordance with the National Minimum Standards. Daily records for each individual are written in one central book. This would make it difficult for residents to view what was written about them, or share this with other professionals or relatives. It was noted that information from the daily record was then transferred to various records – activities, contact with relatives and health. If this was to be recorded on an individual record then information would be more person centred and more accessible for a specific individual rather than trawling through all residents’ daily entries. Daily entries were well-written and provided good evidence of how the home was supporting each individual. It was noted for one individual that a risk assessment was no longer relevant due to changing care needs, whilst this had been reviewed and updated it was not until you had reached the end of the documentation that it became clear that this person was no longer undertaking this task independently and increased staff support was required. A suggestion would be for this to be updated and reflect current practice to reduce confusion for staff. This was being undertaken by the second day of the inspection. Demonstrating a proactive approach to meeting the National Minimum Standards and compliance with the legislation. Care plans and risk assessments provided evidence that the home was committed to ensuring that resident’s independence and individuality was maintained. Residents were evidently involved in the planning of their care. Care plans were designed with the individual in mind. Care reviews provided evidence that residents were consulted and included. Where relevant other professionals and relatives had been involved in the planning of the care. All resident surveys stated that they were aware that they had a care plan and were involved in making decisions. Relative questionnaires confirmed that they were consulted and informed of any changes to the plans of care. A resident confirmed that a key worker system was in place in the home, describing how they had been supported to apply for college courses, purchase clothes and plan regular trips out. Staff conveyed a similar role in supporting specific individuals. However, it was evident that whilst each individual had a named member of staff, this did not curtail relationships being built outside the key worker role. All completed resident surveys confirmed that regular resident meetings were held in the home. Minutes seen provided evidence that in the last six months there have been two meetings. Discussions included menu planning, holidays and activities. A member of staff stated that these are regular planned (monthly) meetings but individuals prefer to spend time in their bedrooms or Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 12 go out with relatives so they are less frequent. A recommendation would be for the home to record this information. Staff, the manager and residents spoken with stated that there was a high level of involvement in household tasks. One resident stated that they clean their bedroom, whilst another stated that they helped the domestic assistant with routine cleaning of the home and cooking. Development plans were in place detailing resident involvement. From conversations with staff this was led by the resident and whether they wanted to participate. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are encouraged to lead full and active lifestyles both in the home and the community. Residents are supported to make contact with friends and family. A wholesome diet is available based on the choice of the individual. EVIDENCE: Residents have available to them a structured day care plan. It was evident that this was tailored to the individual. Six of the residents have a five day placement at a resource and activity centre, another attends a day centre for individuals with autistic spectrum disorder and another has activities organised by the home. It was evident that the residents were actively involved in the reviews of the placements to ensure that they are happy. Regular meetings were organised with day care placements to ensure all parties were happy with the arrangements. Two residents confirmed that they were supported to make full use of the community including attendance at college courses, going out for meals, and Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 14 going to the gym and the theatre. Another resident stated that seven of the residents were going on holiday to Butlins. Records and conversations with staff further confirmed that there was a wide range of activities available to individuals. The home has a large garden shed, which is being used as an activity area for arts and crafts and playing musical instruments. A member of staff stated that this is used regularly on a Tuesday evening for hobbies. Activities were seen to take place both in the evening and at weekends. Care records included information about contact with friends and families. A resident confirmed that they could telephone relatives. The home maintains a record of contact with families in care files. The home maintains a record of visitors and visiting arrangements were included in the statement of purpose. Resident surveys confirmed that they were supported to maintain contact with friends and families. A resident stated that they had recently been supported to visit a previous placement and they had seen staff from many years ago. Positive communication was observed between staff and residents throughout the site visit. Staff included residents in the conversations. Resident surveys provided evidence that privacy was respected, with six residents having access to a key to their bedroom door. Staff were observed knocking on doors prior to entering. It was evident that the home promotes independence. Some of the individuals had control over their personal allowances and one individual self medicates, and others access the community independently. However, since the last inspection three residents now do not manage their medication. The home is in the process of exploring options to minimise the risks to the residents in relation to storage and safety re residents having a months supply of medication. One individual in part self medicates. A requirement was made at the last inspection for the home to develop a policy on self-medication. This remains outstanding. The provider has confirmed that the home is liaising with the local pharmacist in drawing up a policy on self-medication. The residents in the home had a varied and nutritious diet based on choice and preferences. The resident’s surveys, records and conversations with residents confirmed this. Kitchen cupboards were well stocked with fresh fruit and vegetables available. Residents stated that they could help themselves and were involved in shopping for the food for the home. One resident stated that they assist the domestic assistant with the cooking and that they enjoyed this role. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 15 Kendall House DS0000003370.V301814.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): 18,19,20,21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Resident’s personal and health care needs were being met. Residents are now protected by robust medication systems including recording, and this should be extended to resident’s as and when required medication. The home is being proactive in ensuring that the staff are competent in meeting the care needs of residents, as they get older. EVIDENCE: Information in care plans clearly documented how staff should support individuals with both their personal and health care. These were kept under review and updated as needs change. Systems for monitoring an individual’s well-being were in place and concerns about health were quickly addressed. Residents have access to other health professionals including a GP, opticians, chiropody, dentist and the community learning disability team. Staff have attended training in first aid, manual handling, safe administration of medication and supporting an individual with dementia. The home has a Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 17 comprehensive planner for training to ensure that periodic updates are undertaken. Individuals had a distinctive style demonstrated by their choice of haircut and style of clothes. One resident stated that they had been supported by their key worker to go shopping for new clothes for their annual holiday. The home is informing the Commission for Social Care Inspection some of the reportable incidents as per regulation 37. However, there were two incidents of a resident becoming angry with staff and a resident and another where an individual had slipped whilst getting out of the bath and this had not been reported. It was evident that both incidents had been responded to appropriately initiating contact with other professionals for advice. Reports of these incidents were available on the second day of the inspection. The incident relating to the aggression was discussed at the last inspection including how the home was reviewing the individual’s care. This is now having an impact on the other residents living in the home with two complaints about the individual’s behaviour being voiced. Whilst it was evident that this was still being discussed with the appropriate professionals this must be balanced with the needs of the other residents. Staff and the manager described how the home was positively supporting the individual with additional staffing. Staff stated that the manager reviewed all episodes of aggression and looked at ways of how the situation could have been reduced or alleviated. This is good practice. The home has addressed requirements and recommendations from the last inspection relating to medication. Residents now benefit from having individual medication records. There was clear guidance for staff on the administration of medication supplementing the medication record with information on the side effects of each medication. However, as and when required medication still remains in a central book for all residents and a medication label on a bottle was unreadable. A member of staff contacted the pharmacy during the inspection to rectify these issues and this had been resolved by the second day of the inspection. This is good practice. At the last inspection it was recommended that the home seek advice from the GP on the use of homely remedies to ensure compatibility with prescribed medication. The manager and staff stated that the home has good contact with the local surgery and homely remedies are rarely used as individuals see the GP. However the manager stated she could see the rationale and would consult with the GP for each individual. At the last inspection it was noted that there was no policy relating to individuals that self medicate. Three people at the last inspection were selfmedicating, a member of staff stated now only one person self medicates in part as the risk was too high if a resident had 28 days supply of medication. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 18 There was still no policy on self-medication and this remains an outstanding requirement. A risk assessment was in place for the one individual that selfmedicates and this had been kept under review. The home is registered for individuals aged between 18-64 years and all residents fall between these ages. The home is planning ahead and ensuring staff are competent to meet the needs of residents as their get older. This is good practice. The home is supporting an individual with early-age onset dementia. Training was seen that some staff had attended courses relevant to the older person and all staff had attended training in dementia. One member of staff is further building on this training in dementia by completing a distant learning pack, which is based on the Skills for Care occupational standards. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are protected by the home’s policies and procedures in the event of a complaint being raised or if an allegation of abuse is reported. EVIDENCE: The home has good procedures for responding to complaints and concerns. The manager and the provider audit these at regular intervals. The home has had two complaints since the last inspection. Evidence was provided that these were responded to appropriately with the individual who raised the concern. Resident’s comments from surveys provided further evidence that individuals knew to who they should voice their concerns or complaints, which included the manager, staff and family. The home has a policy on addressing issues of abuse. This was seen at the last inspection and met with the legislation. All staff attend compulsory training on recognising and reporting incidents of abuse. This is good practice. Two staff confirmed attendance and the importance of reporting. All staff attend annual training in supporting individuals that may be challenging. This was confirmed in training records. Finances were checked for three residents. Residents were signing for their finances where able. This is good practice. Two staff signatures supported where residents were unable to sign the record. Receipts were seen for Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 20 expenditure. There was a clear accountable system in operation. Care plans included details on individuals support needs relating to finances. Staff attend training on equal opportunities, anti-discriminatory practice and bullying and harassment as part of their induction. This is good practice. It was evident from talking with staff and the manager that these were imbedded in the core practices of the home and the organisation. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 21 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, 25,26,27,28 29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents live in a homely, comfortable and safe environment, which meets the care needs of the residents. EVIDENCE: Kendall House is located in the village of Warmley. There are shops, a post office, a church and open spaces close by. The property is in keeping with the local neighbourhood and looked well maintained internally and to the exterior of the home. All areas of the home were maintained to a high standard. There was a good response to repairs as evidenced from the repair book and the monthly audit of repairs. All areas were clean and tidy, safe and comfortable. The home meets all the relevant standards relating to communal space, bathrooms and bedrooms. Bedrooms seen were personalised by the individual. All residents have access to a single bedroom. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 22 The home has replaced the kitchen in response to a recommendation from the last inspection. Positive comments were received from staff and residents about the refurbishment including plans for new flooring and a dishwasher. There were appropriate aids and adaptations to meet the needs of the individuals living in the home. It was evident from conversations with the manager and records seen that the home would consult with the appropriate professionals if any aids or adaptations were required to improve the lifestyles of the individuals living in the home. Kendall House has two bedrooms and a bathroom situated on the ground floor, however, the home would not be suitable for an individual with physical disabilities due to the stairs that access the garden and the lounge/diner. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 23 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): 31,32,33,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Sufficient and competent staff support residents. There are good systems in place monitoring staff training, supervisions and support networks for staff ensuring continuity of care for the residents. The home’s recruitment processes protect residents. EVIDENCE: The staff rota provided evidence that the home is adequately staffed according to the assessed needs of the residents and the statement of purpose. The home is staffed with two staff during the day, three staff during the evening and one member of staff providing sleep in cover. In addition the inspector saw evidence that the home exceeded the minimum staffing to enable residents to attend social outings and clubs throughout the week. The home employs in addition to the care staff a domestic assistant three days a week complimenting the skills of the care staff. A concern was raised by a relative that the manager did not work weekends. Discussions with staff, the manager and a review of the rota demonstrated that the home was adequately supported. A senior carer is rostered on at the weekends and the manager works Monday to Friday. Staff stated the manager Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 24 and the provider is contactable at all times. It was evident that staff felt supported. Staff had a good understanding of their roles and had clear responsibilities within the team. Staff spoken with conveyed a good team spirit where moral was high with good levels of job satisfaction. This is good practice. Staff spoken with during this site visit were knowledgeable about the care needs of the individuals both collectively and as individuals. There was a strong commitment to providing individualised packages of care and enabling residents to be as independent as possible. The home has employed one person since the last inspection. All information to demonstrate a robust recruitment process was in place. Staff training records were viewed. The commitment to training is commendable relating to statutory training in that there was a clear record of training undertaken and when future training was required. There was a comprehensive induction in place, which linked to the Skills for Care occupational standards. All staff were undertaking a distance learning pack on the safe administration of medication. In addition there was training that had been undertaken and planned around the needs of the individuals living in the home including challenging behaviour, autism, mental health, supporting residents with dementia and getting older. This is good practice. There is a commitment from the organisation to ensuring that the home has 50 of the workforce obtaining an NVQ in care. The senior carer has an NVQ 3, and one carer has an NVQ 2. A further 4 staff are in the process of either completing or enrolling to complete an NVQ in care. The manager is an NVQ assessor and plans to support the staff through the process. Staff spoke positively about the training available to them. All staff are expected to attend a course in anti-discriminatory practice and bullying and harassment as part of their core training. Further supporting the organisations policies on equal opportunities and valuing both the residents and the staff. There were systems in place to ensure that staff were supported, including staff meetings, supervisions with senior staff or the manager and an annual appraisal. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 25 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): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents benefit from living in a well managed and safe environment. There is an open and inclusive culture. EVIDENCE: Mrs Julie Smith is the registered manager. She has worked at the home for the past ten years. She in is the process of completing an NVQ in care and management and has recently completed her NVQ Assessors Award. Evidence was provided that she continues to keep up to date with regular attendance at training courses relevant to her role and the care needs of the residents. Staff spoke positively about the management structure and the support networks in place. All staff spoken with stated that they enjoyed working in Kendall House and for the organisation. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 26 The home has a relaxed and friendly atmosphere. Residents were seen congregating in the kitchen drinking tea after their work placements. Residents were keen to share their days experience and staff were attentive to their needs. There were good systems of communication between staff including daily handovers, records and meetings both for the staff and the residents. The home has had two residents meetings since January 2006. It would be recommended that consultation with residents take place to ensure that these are at the appropriate frequency. Health and safety monitoring was in place both by the manager and an organisational Health and Safety Manager. It was evident that these robust systems protect both staff and the residents. Fire records were in order and included checks on the equipment, a record of fire drills and the training of staff. These were at the appropriate intervals. A fire risk assessment was in place. Staff had attended training in health and safety and this was on an annual rolling programme with updates planned throughout the year. Policies and procedures were in place relating to health and safety including risk assessments. These had been kept under review. There was no evidence that the home was not financially viable. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 27 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 X X X 3 X Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 28 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 YA20 Regulation 13 (2) Requirement For the home to develop a policy on self-medicating. (Outstanding since 01/12/05) Timescale for action 28/08/06 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. Refer to Standard YA6 YA38 Good Practice Recommendations For the home to review the recording of daily records in a central book ensuring that residents’ confidentiality is maintained. Seek the views of residents on how frequent residents meetings should be held. Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Kendall House DS0000003370.V301814.R01.S.doc Version 5.2 Page 30 - 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. 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