Inspection on 29/06/05 for Kendall House

This inspection was carried out on 29th June 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kendall House 27/06/06

Kendall House 02/11/05

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 Glous BS30 8BU Lead Inspector Paula Cordell Announced 29 June 2005 09:30 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 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 Stationary 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 D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kendall House Address 15 Wesley Lane, Warmley, South Glous, BS30 8BU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0117 9602508 0117 9566050 mailbox@themanorhouse.org Mrs Marilyn Clarke Mrs Julie Ann Smith Care Home for Younger Adults 8 Category(ies) of LD Learning Disability for 8 registration, with number of places Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 8 persons aged 18 - 64 years requiring personal care only Date of last inspection 23 February 2005 Unannounced 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 accomodation and personal care to eight persons with a 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, participation, valuing people, equality, rights and working together. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection conducted over 7.5 hours. The purpose of the visit was to review the progress to the requirements and recommendations from the previous inspection and monitor the quality of the care provided to the individuals living at Kendall House. There have been no additional visits during this period. The home has been keeping the Commission for Social Care Inspection informed of incidents that affect the wellbeing of the individuals living at Kendall House and the provider has sent monthly appraisals of the service. The inspector had an opportunity to meet with the manager, three staff and eight residents. The inspector had an opportunity to tour the building and view a number of records including plans of care for two residents, staff records and records relating to the safety of the home. Views were sought from the pre-inspection questionnaires (6 relatives), a visiting relative and in discussion with the individuals living in the home. The inspector would like to take this opportunity to thank the staff and the residents for their warm welcome and assistance in the inspection process. What the service does well: The organisation has supported residents with a learning disability for many years. A number of residents have lived in the home since it opened eleven years ago. There is a strong commitment to provide residents with an individual life making full use of the community, living within a homely environment. Residents have a wide range of activities available to them. Seven of the residents have access to an external day centre in the community five days per week, demonstrating a commitment to providing residents with activities and occupation. Another resident has activities organised by the care staff on a daily basis. Residents are supported to build good links with families and friends. Residents are provided with a homely environment. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Residents would benefit from having their care reviewed at the appropriate intervals at least every six months. The process of reviews must be clearly documented in the statement of purpose. It is strongly recommended that care files be reviewed to ensure information is more accessible and current. Residents would benefit if staff completed training in dementia and undertake an NVQ appropriate to their role further building on the skills and the knowledge of the team. Residents would be safeguarded if medication was stored in accordance with the legislation and remain in their original packaging. It is recommended that the home reviews all policies and procedures and the statement of purpose to ensure the correct details of the Commission for Social Care Inspection are available to residents and their relatives. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 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. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4,5 Residents had sufficient information to enable them to make a decision whether to move to the home. Residents assessed care needs were being met. EVIDENCE: The home has a statement of purpose and a service user guide available to residents and their families. This met with the legislation in all areas except that it stated care reviews were annually and failed to state six months in accordance with the legislation. A relative commended the home on the assessment process and how smooth the transition was for the individual to move to Kendall House. The process took place over a couple of months and included visits to the home and involvement in social trips to enable the individual to get to know the home and the other residents. The manager stated that it was important that the existing residents were involved and to ensure that the new person was compatible with the group. The home has policies and procedures on the assessment process for new admissions. This information is included in the statement of purpose and the service user guide, which is shared with professionals, residents and relatives. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 10 The home has been opened for eleven years and seven of the eight residents have lived in the home since it opened. The last admission to the home was in June 1999. Information in care folders demonstrated that assessments were ongoing and care needs were being reviewed and updated as needs changed. There was a strong commitment that individuals are involved in the planning of their care and support needs. The home was able to demonstrate that they were meeting the changing needs of the individuals living in the home. One of the residents has recently been diagnosed with dementia. The manager stated that this was becoming his primary care need. The home must apply for a variation to include the category of dementia in respect of this named individual. As part of this requirement staff must undertake training in dementia. Staff on duty demonstrated through discussion and observation that they had a good understanding of the needs of the individuals living in the home and how to meet them. Contracts were seen at a previous inspection and met with the legislation. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 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 standard(s) 6,7,8,9,10 Residents were involved in the planning of their care, however, the home failed to demonstrate that plans of care were being reviewed on a six monthly basis. EVIDENCE: Each person had a care plan and skills development plan that detailed the action taken by staff to enable residents to meet their care needs and achieve personal goals. Two plans were examined in detail. Information was person centred and written in the first person. 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. Care files would benefit from information being archived if no longer relevant. Amendment sheets noted ongoing changes to plans and these have been used to update plans to show the changed needed. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 12 It was noted that plans were not being fully reviewed every six months. Some plans had been reviewed and others had still to be reviewed. There was a strong emphasis in the home of the promotion of residents’ independence through systematic planning and a skilled staff team. Residents told the inspector about the key worker role and the support that individual staff gave them. A relative told the inspector that the home keeps them informed of all changes to the plan of care and invited them annually to a care review. Staff described how they involved the individuals living in the home in making decisions about their day-to-day lives and their plans of care. Assessments and management of risks arising from care plans and safety in and out of the home had been undertaken. The inspector commends the service for the approach to risk assessments, which covered all activities undertaken. Documentation provided evidence that the risk assessment tool ensured the safety of residents but did not curtail or inhibit residents and encouraged independence and community participation. This is good practice. Residents stated that they have meetings in the home and are involved in the planning of activities, menu planning and choice of décor of their bedrooms. Staff, the manager and residents spoken with stated that there was a high level of involvement in household tasks. One individual stated that they assisted with the cleaning and the cooking. It was evident that they enjoyed this and felt valued and empowered. Records were held securely. Staff were aware of the need for confidentiality and had signed policies relating to this topic and data protection. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 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 standard(s) 11,12,13,14,15,16,17 Residents were encouraged to lead full and active lifestyles based on personal choice. EVIDENCE: Residents on return from their day centres were keen to share with staff their experiences of the day. Communication was positive and inclusive of the individuals living in the home. Residents spoken with described the many social activities that are available to them including meals out, clubs, trips to places of interest, shopping trips, swimming, attendance at a local gym to name just a few. This was echoed by a visiting relative who stated that individuals in the home had lots of opportunities to go out in the community including encouragement of hobbies and relaxation in the home. Residents stated that they have an annual holiday every year including short weekend breaks. In addition some of the residents had holidays with relatives. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 14 Residents were excited about their pending holiday and the preparations leading up to it which included some people going on shopping trips to purchase new clothes with their key worker (individually named member of staff). There was a strong commitment from staff in providing individuals with opportunities to experience every day life and making full use of the community. Residents spoken with stated that they attend clubs and one individual attended a drama group. It was evident from discussion with staff that they were proud of the individuals’ achievements. Each individual had a structured day care plan. From discussion with the manager and the staff it was evident that good links had been established with the day placement staff to ensure a consistent approach and to ensure that all parties are happy. Residents showed confidence in their communications with staff, each other, and the inspector and in tasks they were undertaking. Individual plans included information on how the person communicated and what made them cross and happy. It was evident from discussions with residents, staff and the manager that there were no restrictions on individuals using the community. The home has a car for trips further a field. Care plans and risk assessments clearly described the support needs of the individuals. Residents stated that they had keys to their bedrooms and could if wanted lock their bedroom doors. The manager stated that many of them prefer not to lock their doors. Residents were seen accessing all parts of their home. From reading the plans of care it was evident that there was a focus on individuals being independent. Some of the individuals had control over their personal allowances and medication. This was clearly documented and safeguards were in place to ensure the safety of the individual. This is good practice. Evidence in care records demonstrated the home was committed to supporting individuals to maintain contact with relatives and friends. A relative stated that they were always made welcome were offered refreshments and or a meal and actively got involved in the home. In fact on the day of the inspection they were assisting with the garden. Residents spoken with talked of parties and the annual barbeque to celebrate the anniversary of the opening of the home. Preparations were under way for to celebrate eleven years with invites being sent to friends and family. A relative commended the home on the contact that was maintained, including frequent telephone calls and the involvement in the annual reviews. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 15 Menus were seen and demonstrated that the individuals living in the home had a balanced and varied diet based on choice. Dieticians had been consulted on the meal planning in the past. From conversations with staff the home could and would cater for special diets and preferences of the individuals in the home. Care plans included dietary requirements and preferences. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 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 standard(s) 18,19,20,21 Residents personal and health care needs were being met, however, the home failed to demonstrate that medication was stored safely. EVIDENCE: Care plans clearly documented the personal and health care needs of the residents. Systems for monitoring an individual’s wellbeing were in place and concerns about health were quickly addressed. Residents had access to other health professionals including a GP, opticians, chiropody, dentist and the community learning disability team. Staff have attended training in first aid and manual handling. The home has developed a comprehensive planner for training to ensure that periodic updates are undertaken. Plans of care included individual assessments for manual handling. Training for staff was in place. The home has robust procedures and practices on the administration of medication, including a comprehensive induction and training package for staff. However, the home must ensure that the medication is secure. Surplus stock was in an unlocked cupboard and insulin was stored in an unlocked fridge in the garden shed. In addition medication (paracetamol) was not being kept in Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 17 its original packaging giving the impression that they were out of date as the container had a date of 10/04. The manager addressed this at the time of the inspection. As part of this inspection process the inspector has requested a visit from the Commission for Social Care Inspection’s pharmacy inspector. The focus of this visit will be the home’s system for recording medication as the senior staff writes this. Good practice would be for the home to have printed medication records from the dispensing pharmacist. Policies and procedures were in place to guide staff and information was sought as part of the assessment process on how individuals would like to be supported in the event of a death including contacts. A relative confirmed that they had been consulted in their event of their own and the individual’s death. The inspector was informed that this was done sensitively. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 18 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 standard(s) 22,23 Residents and relatives were confident that complaints would be responded to appropriately and individuals were protected from abuse. However, staff attending training in the protection of vunerable adults could enhance this. EVIDENCE: The home has a robust complaints procedure in place. Residents and relatives were confident that a complaint would be taken seriously and responded to in an appropriate manner. Information was gained from relative questionnaires and through discussion with residents and one relative. Where concerns had been raised this had been investigated and appropriate action taken involving the complainant. A relative stated that they were very happy with the home, the warm welcome they receive from staff and the residents and have had no reason to complain. The home has procedures for the protection of individuals living in the home including an abuse, bullying, anti-racism, financial, gifts and a whistle blowing policy. Staff were aware of the procedures to safeguard residents. There was a strong awareness of the individuals’ rights. There was a requirement for the home to ensure that staff undertake training in prevention of abuse. The manager provided evidence that abuse and the whistle blowing policy had been discussed at a recent staff meeting. Further training was being arranged by the Organisation and a senior manager has attended a train the trainer course on abuse. The plan is for this to be cascaded to all staff over the next six months. The timescale for this requirement has been extended to enable the home to comply. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 19 Finances were checked. These were found to be satisfactory and safeguards in place to protect the individual’s monies including regular checks, receipts and two staff signatures was in place. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 20 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 standard(s) 24,25,26,27,28,29,30 Kendall House provides a comfortable, homely and safe environment for individuals to live and work. 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. All areas were clean and tidy, safe and comfortable. All bedrooms were personalised and decorated and furnished to a high standard. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 21 The home has one double bedroom. The residents sharing the room said they were happy to do so. There was screens (curtains) situated appropriately in the room to offer individuals privacy should they wish to. This is good practice. There were sufficient bathing and toilets situated in the home. Bathrooms were clean and comfortable. All shared space was domestic in style and consisted of an open plan lounge/dining area and a kitchen. The kitchen was a well-used area of the home. All residents congregated here to have a cup of tea after they finished they work placements and to chat about their day. There was a spacious mature garden, which had a patio area with seating. To the rear of the property is a hobby room and a green house. Residents and staff said that the hobby room is accessed on a regular basis. This was well stocked with music equipment, games including a pool table and art and craft materials. A number of the residents said they enjoyed the support staff gave to them with their art and crafts and hobby sessions. 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 was 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 D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 22 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36 Competent staff supports residents however, the home needs to ensure that they can meet the target for 50 of the workforce to have an NVQ in care and for staff to attend training on dementia. EVIDENCE: From discussions with staff and the manager, the team has been through a period of change with only three of the original staff now working in the home. The manager stated that this change has taken place over the last twelve months and was seen as positive from everyone spoken to during the inspection process. Staff commended the support and guidance that the manager and the senior carer had given them during their induction process. It was evident from discussions that the new team were working well together and their were clear roles and responsibilities shared amongst the team. Residents evidently liked the staff on duty and were keen to share their experiences. Staff were knowledgeable about the care needs of the individuals living in the home and there was a commitment to providing individualised packages of care and enabling the residents to be as independent as possible. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 23 Staff records were reviewed. All staff recruited since the last inspection had the appropriate information to demonstrate that a thorough recruitment practice had taken place. There were gaps in references for staff employed prior to the last inspection. The home was able to demonstrate in part that they had met the requirement to ensure that two references and a criminal record bureau check is in place prior to offering a position to new staff, the manager said that copies of the missing references would be requested from the main office of the organisation. There was a comprehensive induction in place, supervision and ongoing training. There is one requirement for staff to undertake training in dementia and for the home to develop a plan on how they intend to ensure that 50 of the workforce have an NVQ 2 in care. In all other areas there was training planned relevant to the needs of the individuals living in the home. Out of a team of eleven staff only two staff have an NVQ in care, which is the manager and the deputy both have an NVQ 3 in care. The manager is in the process of completing an NVQ 4 in care and management and has successfully completed the NVQ Assessors Award. The manager stated that the organisation is committed to provide a trained workforce including NVQ but many of the staff are new to the role of carer at Kendall House and the home is focusing on ensuring a comprehensive induction is completed. The manager stated that three staff are planning to enrol for NVQ 2. One member of staff is 19 years of age, evidence was provided that they are not left in charge of the home. Staff had signed policies and procedures and the General Social Care Council’s code of conduct. Staff stated policies are discussed as part of the induction and discussed at regular intervals at staff meetings. Evidence was provided that meetings occur on a monthly basis. Various topics are discussed demonstrating that there is good open communication within the team. The staff duty rota provided evidence that the home was staffed according to the assessed needs of the individuals living in the home and the statement of purpose. The home is staffed by two staff during the day, three staff during the evening and one member of staff sleeping in to provide individuals with contact in the case of an emergency. In addition the inspector saw the home exceeded this to enable individuals to go out in the local community and attend clubs. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 24 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Residents benefit from living in a safe environment and a well managed home. EVIDENCE: Mrs Julie Smith is the registered manager. She has worked at the home for the past ten years and was successfully registered as the manager in April 2004. She is in the process of completing an NVQ 4 in care and management. Staff spoke positively about the management structure and the support networks in place in the home to enable them to fulfil their roles as care staff. Two relatives commended the management of the home. The home had a relaxed and friendly atmosphere with a focus upon promoting residents’ independence that was facilitated and encouraged by the manager. All staff spoken with stated that they enjoyed working at Kendall House. There were good systems of communication between staff including daily handovers, records and meetings both for the staff and the residents. This Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 25 demonstrated that there was an open culture and support mechanisms both for staff and the service users. The home is commended on the quality assurance systems in place ensuring that Kendall House provides a quality service. Audits were completed on aspects of the home including seeking the views of the residents and their relatives. In addition the provider completed a monthly audit on the home in respect of the Care Homes Regulations. The Commission for Social Care Inspection is receiving copies. Health and safety in the home was monitored both by the manager and an Operational Health and Safety manager. Health and safety training for staff was in place to ensure that residents are protected and supported by competent staff. Fire records were viewed and found to be satisfactory. However, it was difficult to determine if staff working nights had attended three monthly fire training as this was recorded in the fire register and staff minutes. The manager has agreed to review the recording of the fire training to ensure that this is contained in one folder for easy reference. There were a number of generic risk assessments on the environment, household and care activities and accessing the community. This demonstrated that residents were supported and enabled to be independent as possible and risk assessments whilst ensuring safety did not hinder or restrict individuals. The home has an extensive policy file to guide staff and support the residents. It was evident that the residents were the focus of the policies. The home has recently reviewed a significant number of the policies. A recommendation would be to ensure that the information relating to the Commission for Social Care Inspection is correct. This inspection did not focus on the financial viability of the home. There was no evidence that the financial viability of the service was threatened in any way. The organisation has a business plan. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 26 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 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kendall House Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 x D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 27 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 1,6 Regulation 4 Schedule 1.15 15 (2) (b) 18 (1)(c) Care Standards Act Requirement For the statement of purpose to be amended to include the review of care records as per the legislation For care plans to be reviewed six monthly. Staff to attend dementia training. As part of this requirement the home must apply for to vary the homes certificate of registration to include DE for one named individual. For medication to be stored in accordance with the medicines Act 1968 and the jguidelines issues by the Royal Pharmaceutical Society. To ensure that medication remains in the packaging as despensed by the pharmacist The registered provider to ensure all staff are up to date with their training in the Protection of vulnerable adults For the registered provider to develop a plan on how they will achieve 50 of the workforce to have an NVQ 2 by 2005 Timescale for action 29/7/05 2. 3. 6 3, 33,35 29/9/05 29/7/05 4. 20 13 (2) 13/7/05 5. 6. 20 23 13(2) 13 (6) 29/6/05 29/10/5 7. 32 18 (1) (c) 29/8/05 Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 28 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. Refer to Standard 1,22 6 Good Practice Recommendations For the statement of purpose, complaint procedure to be updated with the correct details of the Commission for Social Care Inspection. For care information to be archived where the information is not current or relevent. Kendall House D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection 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 D56 D05 S3370 Kendall House V226363 290605 Stage 4.doc Version 1.30 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. 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