Inspection on 10/01/06 for Keneydon House

This inspection was carried out on 10th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Keneydon House 07/04/09

Keneydon House 08/04/08

Keneydon House 14/05/07

Keneydon House 23/05/06

Keneydon House 23/06/05

Keneydon House 21/01/05

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Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Keneydon House 2 Delph Street Whittlesey Cambridgeshire PE7 1QQ Lead Inspector Don Traylen Unannounced Inspection 10th January 2006 09:30 X10015.doc Version 1.40 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 Keneydon House DS0000061370.V273863.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 Older People. 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. Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Keneydon House Address 2 Delph Street Whittlesey Cambridgeshire PE7 1QQ 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) 01733 203444 01733 202648 ADR Care Homes Ltd Eileen Redhead Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (21) of places Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Old Age not falling into any other category (OP) - 21 (both sexes) Dementia - over 65 years of age (DE(E) - 21 (both sexes) Date of last inspection 23rd June 2005 Brief Description of the Service: Keynedon House is a care home registered to provide for 21 people over the age of 65 years. The home is situated in the town of Whittlesey, near Peterborough and is close to local amenities. The home is an older property built approximately in 1890.The accommodation is on two floors accessible by stairs or a chair lift to the first floor. There are 13 single and 4 double rooms and a large garden to the rear of the building. A ground floor extension housing six bedrooms was built approximately 15 years ago. The home provides day care provision on Mondays, Wednesdays and Fridays for 1-3 people as well as preparing and delivering meals for up to 14 people who live in the immediate vicinity. The day service users share the same facilities enjoyed by the permanent service users living at the home. Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out by two inspectors. The registered manager was present during the inspection. One visiting relative and two care workers were spoken to and observations were made of a group of 9 service users who were seated in the lounge. 19 service users were living in the home at the time of inspection. Records of staff recruitment and staff training were read. The reader is referred to the comments made in the last inspection report conducted on the 23 June and 18 July 2005. What the service does well: What has improved since the last inspection? Structural maintenance has been made to the roof. Some progress has been made in arranging for quotations for redecorating. Further relative’s meetings have been arranged. Staff training has continued and more training has been delivered to staff. A new manager has been registered. The manager has contributed to the improvements and has re-organised staff training records and policies and Care Plans. She has made these records easy to identify and well presented. She has also made a number of further arrangements for staff training including NVQ awards. The manager has responded positively to the four Recommendations made in the last inspection report. Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 6 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. Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, Service users and their representatives would benefit from clearer arrangements for contacting CSCI should they wish to make a complaint. EVIDENCE: The Statement of Purpose and Service User Guide had been updated in October 2005. The two documents referred to the National Care Standards Commission and did not include the correct name and address and telephone contact for the CSCI. Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9, Service users are protected by the homes approach to administrating medication. EVIDENCE: No service user self-administers, or manages their own medication and no supplies of medication are retained by any service user. Service users are assessed for handling their own medication. Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,15, Service users are enable to retain family contacts. EVIDENCE: A friend of a service user who moved into the home in December 2005 was visiting during the inspection and informed the inspector that during his daily visits he has noticed that staff are kind and considerate to service users. The manager stated that she to asks service users about their feelings on a frequent basis. Further relatives meetings have been arranged and the next one is scheduled for 26/02/2006. Service users are given choices of meals and these are established in advance so that a weekly menu is decided. A wholesome meal of fish and fresh vegetables was observed being prepared. A pleasant aroma of homemade cakes the cook was making gave a homely atmosphere during the inspection. Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18, More intention and action is necessary to ensure that any allegation or suspicion of abuse is reported immediately and appropriately and could be reported by visitors to the home. EVIDENCE: The home has a complaints records book that contained only one recorded complaint made in December 2004. The complaint had been accurately recorded and responded to. Comments made in “Choice of Home” section identifies the omissions from the Statement of Purpose and Service User Guide that did not adequately refer to whom, or where a complaint could be made. A recent allegation of abuse had not been immediately reported by the home. A delay of between two and three days had occurred before it was reported. The home did not have a policy to protect vulnerable persons from abuse although they had a copy of Cambridgeshire County Council’s guidelines for protecting vulnerable adults from abuse. The guidelines did not include contact details for reporting allegations or suspicions of abuse. There were not any contact details available or visible in the office or in any other area of the home. It was discussed with the manager that should an allegation of abuse be raised, it must be reported immediately and that staff must have sufficient and easily accessible information of where to report this. It was also discussed with the manager that the information for the Police and for the PCT/Local Authority contacts must be easily accessible and visible and open to staff and to visitors to the home. It was agreed that the manager would facilitate all staff and enable them to report any known or suspected abuse and that they have a legal responsibility to protect vulnerable person in their care. It was also agreed that reporting of abuse must not be delayed and that it must be Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 12 carried out immediately. The manager informed the inspector that she has arranged to attend a three-day training course to enable her to train her staff in adult abuse protection matters. The manager informed the inspector that the registered provider had recently attending this training offered by the local Authority. Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,26, The environment is in need of improvement. EVIDENCE: A requirement made in the last inspection requested a written plan from the registered provider to send the CSCI a copy of the proposed maintenance and improvements intended. This has not been received by the CSCI. Repairs to the roof have been carried out. A tree outside the main entrance has been pruned to allow more natural light. The manager informed the inspectors that a handyman is employed to work for approximately 10 hours per week, but it was not evident what his work schedule was or what has been maintained since the last inspection. A maintenance-reporting book contained mostly entries for replacing light bulbs. There was no supporting evidence of a systematic or thorough approach to maintaining the fixtures and fitting or the condition of the building. A strong smell of urine was noticed by both inspectors and was pointed out to the manager who stated the smell would disappear after the cleaners had Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 14 attended to the room. It was later noticed that the odour had dissipated. It was discussed with the manager that the odour smelt as though it was suppressed in the fabric of the carpet and that the carpets may need to be replaced and other options for removing the odour may need consideration. The same unpleasant odour was reported by a Social Worker who visited the home on the previous day, the 9 January 2006. The manager has recently purchased 10 new beds for service users. The home looked clean. Bathrooms, bedrooms, hallway and communal rooms were tidy and were kept clean. Some of the decorative style of the rooms and hallways absorbed light and were dimly lit and should be considered for redecorating to reflect light rather than absorb light. No evidence of consulting service users about sharing rooms was available. Bathrooms are large and are equipped with appropriate bathing facilities for the current needs of service users. Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29,30, Service users are not adequately protected by a recruitment policy or practices. EVIDENCE: One staff file contained two references that were undated. The provider telephoned and informed the CSCI four days before the inspection that only one reference had been obtained for one member of staff in relation to a recent concern. During the inspection a second reference for the same person was found in the file during the inspection that was undated and was not one from one of the referees included in the person’s application form. A CRB was not available for the same person although a POVA first clearance had been obtained. Other personnel in the organisation had incorrectly informed the manager that a satisfactory CRB had been received. The member of staff had therefore been working unsupervised without a CRB. Two other staff files showed that references were not dated. The home did not have a written recruitment policy. Induction training had been arranged and was planned through the Greater Peterborough PMS support project for older persons services. All of the staff induction training had not been included in the staff induction programme. It was discussed with the manager that she would produce a complete list of all induction training and would institute an in-house adult protection training and awareness for new staff. Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 16 Most staff have received training in Dementia care and in protecting vulnerable adults from abuse and further arrangement for the remaining staff to be trained in these two subjects have been made. The manager was asked to check on staff competencies and their ability to report any suspicion or allegation of abuse after they have receiving training in Protecting Vulnerable Adults. 19 service users were living in the home at the time of inspection and 2 care staff, a domestic cleaner and a cook were working. One waking and one sleeping-in night care worker manage the home during the night. The manager provides additional personal care when care workers request her help. As a team they appeared to work effectively and calmly. However, considering the additional day service users the ratio of staff to service users is not best practice and increases the level of risk for service users. Evidence of reviewing staffing levels was made a Requirement at the last inspection and has not been given to the CSCI. Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,37,38, The manager is not sufficiently enabled by the registered provider to protect service users. EVIDENCE: Supervision of care staff has not always been carried out. The recently registered manager has developed her administrative role and also carries out personal care tasks each day. She has made improvements to the collation and presentation of Care Plans, training records and policies. Support for the manager would be improved if the registered provider ensured she was able to manage the CRB application process for new staff. Reporting allegations and suspicion of abuse is a legal responsibility and is therefore a responsibility for the manager all staff and the registered provider. Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 18 Regulation 26 reports carried out by the provider for July to November 2005 were sent to the CSCI in one lot and had not been sent monthly as expected. The same reports had not been given to the manager as required by the Care Homes Regulations 2001. Regulation 37 reports are required to be completed and sent to the CSCI for all incidents of concern. The home did not have policies for Abuse and for Recruitment. Accident records are kept. Overall the management of the home must be improved. Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X X 3 X X 2 STAFFING Standard No Score 27 2 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 2 2 Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 6(a) & 22 & Sch 1 Requirement The arrangement details for dealing with a complaint written in the Statement of Purpose and Service User Guide must include the current name, address and telephone details of the Commission for Social Care Inspection. The home must ensure the safety of service users and write an adult abuse policy and send a copy to the CSCI. The registered manager and the registered provider must ensure that all incidents of suspected abuse and allegations of abuse are immediately reported to the correct lead authority. The registered provider must prepare a written plan of maintenance and improvements and submit a copy of the plan to the CSCI. This requirement was made at the last inspection on the 23/06/05 with timescale set for 01/10/05 and remains unmet. Failure to respond may result in legal action DS0000061370.V273863.R01.S.doc Timescale for action 01/02/06 2 OP18OP38 13(6) 01/02/06 3 OP18 13(6), 18(1)(a) 01/02/06 4 OP19 23(2)(b) 01/03/06 Keneydon House Version 5.0 Page 21 5 6 OP26 OP33 16(2)(k) 18(1)(a), 23(1)(a) 7 OP29 19(1)(a)( b)(c)(5)S 2 18(1)(c [i]) 8 OP30 9 10 OP36 OP38 OP37 & 24(1)(b) 26 11 OP37 37 being taken. The smell of stale urine in various parts of the home must be eradicated. The service must be reviewed to address the staffing levels and the mixed service that the organisation is providing. Evidence of consultation made for this review must given to the CSCI. This requirement was made at the last inspection of the 23/06/05 and remains unmet. Failure to respond may result in legal action being taken. The process for staff recruitment must not deviate from the regulations: 19(1)(a)(b)(c), (5) & Schedule 2. Induction training programme for new staff must include all aspects of induction and arrangements must be made to include protecting vulnerable adult from abuse training. The home must produce a written staff recruitment policy. Reports made under Regulation 26 must be written each month and sent to the CSCI and must be given to the home’s manager to keep in the home. Regulation 37 reports must be completed for all incidents in the home that affect the welfare of service users and staff. 01/04/06 01/02/06 01/02/06 01/03/06 01/03/06 01/02/06 01/02/06 Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 22 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 Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Keneydon House DS0000061370.V273863.R01.S.doc Version 5.0 Page 24 - 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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