Inspection on 09/07/07 for Kenilworth

This inspection was carried out on 9th July 2007.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kenilworth 02/06/06

Kenilworth 04/08/05

Kenilworth 19/04/05

Kenilworth 06/09/04

Kenilworth 22/04/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Kenilworth (Horley) Kenilworth (Horley) 117 Balcombe Road Horley Surrey RH6 9BG Lead Inspector Helen Dickens Unannounced Inspection 9th July 2007 11:00 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 Kenilworth (Horley) DS0000013689.V345647.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. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kenilworth (Horley) Address Kenilworth (Horley) 117 Balcombe Road Horley Surrey RH6 9BG 01293 784299 F/P 01293 784299 kenilworth@theavenuestrust.co.uk glebe.house@theavenuestrust.co.uk The Avenues Trust Limited 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) Joanne Wood Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 30 45 YEARS 1 Named Service user may be aged over 45 years 2 named Service users may have a sensory impairment Date of last inspection 2nd June 2006 Brief Description of the Service: Kenilworth provides a home for six adults with a moderate to severe learning disability and behaviours that may be challenging. Currently there are four males and two females living at Kenilworth. The home is owned and managed by The Avenues Trust, which has a number of similar homes in the Southeast of the Country. Kenilworth is a converted two floor house situated in a residential area of Horley, within reach of the town centre with its amenities. The property has six bedrooms across both floors, with communal areas consisting of bathrooms, kitchen, dining room and lounge. There is also a large garden with a summerhouse that has been partially converted for use as a sensory room for service users to relax in. Current fees range from £1036 - £1799 per person per week. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over 7 hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The Registered Manager, Joanne Wood, represented the establishment. The Service Manager for Avenues Trust joined the inspection for the early part of the afternoon. A partial tour of the premises took place. The inspector met all six residents and spoke to two in more depth. All staff members on duty were also briefly spoken to. Three ‘comment cards’ returned to CSCI, and the Annual Quality Assurance Assessment (AQAA), which was completed by the manager, were also used in writing this report. Two resident’s care plans and a number of other documents and files, including two staff files, as well as risk assessments and maintenance records, were also examined during the day. The Commission for Social Care Inspection would like to thank the residents, manager, service manager and staff for their hospitality, assistance and cooperation with this inspection. What the service does well: Kenilworth offers a homely environment which has improved considerably since the last inspection. The communal areas are very nicely decorated and furnished and residents were very pleased with their bedrooms and the facilities provided. One relative commented that the home creates a ‘friendly, family-like atmosphere’ for residents. Arrangements for ensuring equality of opportunity are good and there are a number of measures in place in this regard. There is a cultural needs assessment on file for every resident, including those from a minority ethnic background. There is also an equal opportunities policy in place and a number of documents have been translated into pictorial and user-friendly formats. The home and grounds are fully accessible to the current group of residents. A number of positive comments were received from relatives who returned comment cards to CSCI prior to the inspection, including one relative who said that they had always been delighted with the way Kenilworth is run and ‘The managerial side of the home is first-rate.’ Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: An immediate Requirement was made regarding the broken upstairs window restrictors in one resident’s room; the manager and service manager arranged for a maintenance man to visit the home and the repair was carried out within a couple of hours. Some requirements have only been partially met since the last inspection. All toiletries, which are not locked away, must have a risk assessment in place; not all bedrooms have got the appropriate furniture; and though the drive has been covered in gravel, the paving around the home at the front is still dangerous. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 7 Some new Requirements were made as a result of this inspection including further guidance is needed on ‘as required’ medication; further work needs to be done regarding shortfalls in the environment; and more risk assessments must be put in place. The home must also take specialist advice regarding their arrangements for the prevention of legionella. 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. The summary of this inspection report can be made available in other formats on request. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective resident’s individual needs and aspirations are assessed prior to admission to Kennilworth. EVIDENCE: The home has not admitted any new service users in some time. At the last inspection the acting manager explained the admission process. In the first instance and following a referral, a community care needs assessment would be requested from the social and health care management teams. Once in receipt of these assessments, the home would visit the prospective service user to carry out their initial needs assessment. Prospective residents would be encouraged to visit the home prior to admission, in order to further assess their needs. Once admitted, the needs assessments would be on-going. The needs assessments sampled were comprehensive and covered all aspects of daily living, indicating that staff would be aware of a service users needs. Kenilworth (Horley) DS0000013689.V345647.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The assessed needs of residents are reflected in their care plans, and they are encouraged to make decisions in their daily lives. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: Two resident’s care plans were sampled and found to contain a good overview of residents needs, with detailed information about how they wished to be supported. A third resident’s wall-plan was also viewed by the inspector though this is currently not on the resident’s bedroom wall as the manager is trying to work out the best way to do this whilst keeping all the components in place. Residents also had an individual daily diary, which has an ongoing record of any activities, and what sort of day they have had. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 11 The plans have been drawn up with specialist input where appropriate, for example one resident had a speech and language therapy assessment. Significant sections of the care plans are in a more accessible format, and each had an easy read version of the complaints procedure on their file. Holistic profiles compiled by resident’s families give a good deal of background information on residents, enabling staff to support them more fully. The home should be commended for their attention to equal opportunities as all residents, irrespective of their ethnicity, have a cultural assessment on file which considers all aspects of their needs taking into account ethnicity, faith, sexuality etc. Residents, not all of whom can speak, are encouraged to make decisions and staff were observed to communicate very well with them. Residents choose when they want to have a drink, they help to choose meals, and they can choose their favourite activities. Files sampled had information from residents on ‘My ideal day’ and ‘My best evening’ showing their views had been taken into account when planning their activities. There is a pictorial booklet produced by Avenues Trust which helps residents go through the arrangements they would like in the event of their deaths – there were copies on both files sampled. On the day of the inspection the home were planning to have a takeaway for supper and one resident was overheard to ask if he could have his favourite fish and chips – the manager arranged this and all residents and staff were sitting down to a supper of fish and chips at the conclusion of the inspection. There are a number of risk assessments in place regarding any potential hazards around the home and residents are encouraged to take reasonable risks in their day-to-day lives. A number of risks have already been minimised, for example water outlets have thermostatic controls to prevent scalding, and radiators have covers. One resident’s file sampled showed there were detailed guidelines in place for staff regarding challenging behaviour, in order to minimise the risk of harm to either the resident or to staff. A number of other risk assessments are needed and these are covered under Standard 42 on health and safety. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are assisted to take part in appropriate activities and be part of the local community. Family and friendship links are encouraged and residents are treated respectfully by staff. Kennilworth offers residents a health diet. EVIDENCE: There were good records of the activities available to residents. There is a weekly planner and both files sampled showed a variety of indoor and external activities for example one resident attended day services and had two sessions funded for 2:1 staff time to support them with their activities; several go to dancing classes; others have some adult education classes for example cookery. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 13 Some residents can participate in domestic activities and are encouraged to help with their laundry and in the kitchen; one resident helped with the hoovering. A record of the actual activities each resident takes part in each day is noted in their daily diary. A relative who completed the CSCI questionnaire prior to the inspection said that their relative at Kenilworth ‘Had a full and active life’ at the home. They also said the home ‘..treats everyone as unique individuals and gives them the appropriate opportunities that they may need.’ There was one negative comment about activities on a comment card returned to CSCI by another relative, and this was discussed with the manager. Residents are encouraged to be part of the local community and use local facilities such as healthcare services, shops, pubs, restaurants and takeaways. Some residents attend day services and adult education classes. Family links are encouraged and staff were very knowledgeable on resident’s family relationships. One relative noted on the comment card to CSCI that they are ‘Always kept in the picture’ about important issues affecting their family member at Kenilworth, and ‘One is always made welcome and made to feel part of a happy community.’ Some families have completed a ‘holistic profile’ for their relative, with very detailed information about their backgrounds and personal history, and this enables staff to cater for their needs more appropriately. Information regarding personal and sexual relationships is also recorded on each resident’s file. Routines in the home are flexible and there are very few ‘set’ times – the exception would be when residents are going to day services or classes where the times are already decided. The food served to residents does not come as a set menu – residents are asked what they would like, according to the shopping already bought, each day. Residents were seen helping themselves to drinks and moving around freely throughout the day. Residents were included in conversations with staff and there were no examples of residents being ignored whilst staff talked exclusively with each other. Resident’s are offered a healthy diet and the menus recorded for each day demonstrated that much of the food is home-cooked. Residents don’t always have the same meal, and where this differs it is clearly itemised on the menu. Residents have their main meal in the evenings and during the last two weeks meals had included pork chops, roast chicken, and a ‘brunch’ which was a lunchtime full English breakfast one Saturday. On the day of the inspection residents had cereals, toast and fruit juice for breakfast, corned beef sandwiches and coleslaw for lunch and their takeaway fish and chips in the evening where they all sat down together. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 14 The manager said the shopping is normally done at the beginning of the week so there was not much food in, though there was plenty of salad, milk and fruit juices in the fridge. Two residents have to watch their weight and the manager said they are given more vegetables and less potato but would otherwise have the same meal as everyone else. The manager has started to compile a book of pictorial food items to help residents to choose menus, and at the moment they are shown packets and containers (e.g. cereal packets) to help them in their food choices. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents receive personal care in the way they prefer, and health needs are met. There are good arrangements in place for the administration of medication though further work needs to be done as set out below. EVIDENCE: Resident’s personal care needs are well documented on their care plans. Residents were dressed very individually and this reflected their personalities. Personal care is delivered in private and there is evidence on resident’s files that they have been included and consulted on the arrangements for their personal care. Specialist support is noted on care plans for example when speech or occupational therapists have given advice. There is a key working system in place to ensure good continuity of care for residents. Residents at Kenilworth have their health needs set down in their health action plan. Two of these documents were sampled and found to contain information on health needs, appointments made and kept, and health screening. The Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 16 plans differ according to residents needs, for example one resident who has seizures had a seizure chart to record and monitor what was happening in that regard. Weights are also recorded regularly though one plan sampled showed a resident had not been weighed for three months and the manager said she would follow this up. There are good arrangements in place for the administration of medication and the home takes advice, and is inspected by, the local community pharmacist under an arrangement with the local NHS. They were last visited in March 2007. The manager has had outside medication training and this meets the Requirement made at the last inspection for at least some staff to have external training on this subject. The manager takes overall responsibility for medication and nightstaff do weekly stock checks of all medication which is not in blister packs. Medication stocks are also checked at staff handover twice per day. The manager was asked to seek advice from the GP and ensure all ‘as required’ medication is documented as such on the medication administration records. There must be written guidance, signed off by the prescriber, for staff regarding when ‘as required’ medication is given. There were no unexplained gaps on the medication administration records except for ‘as required medication’ and the manager was asked to review these arrangements. The inspector took advice from the CSCI pharmacist regarding the potential covert administration of medication to one resident. The registered manager will need to get consent in advance from this resident, and consult their GP, the Care Manager, and any family or advocate involved, and have this clearly documented on the resident’s file. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s complaints would be listened to and they are protected from abuse. EVIDENCE: There have been no complaints received at CSCI about this home, and the home’s own complaints logs shows none have been received at the home either. There is a user-friendly version of the complaints procedure on each residents file. As some residents do not communicate with speech, the residents would rely on staff to be able to ascertain if they had any complaints. Staff were observed to understand the needs of residents and to communicate effectively with them. Two residents have no family and the service has still not managed to find and independent advocacy service to support residents. Some suggestions were made in this regard and this Recommendation from the last inspection will be repeated. There is a safeguarding adults policy in place at this home though the version available on the day of the inspection was an older version from 2003. This, and other out of date policies were discussed with the manager and service manager who agreed to review all policies on file to ensure the latest versions were readily available. There have been no safeguarding issues raised about this home since the last inspection and all staff have had training on this matter. Recruitment arrangements at this home are robust and therefore protect vulnerable people. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment at this home has improved considerably since the last inspection but more work is needed to meet this Standard in full. The arrangements for hygiene and the control of infection are good but more work needs to be done regarding two bathrooms/toilets which are not odour free. EVIDENCE: Kenilworth offers a homely environment and has benefited from extensive refurbishment during the last year. Inside the property most bedrooms have been redecorated to a good standard, as have all the communal areas. The dining room in particular has been very tastefully refurbished. The driveway to the front of the house is new and covered in gravel, and the back garden has improved considerably since the last inspection with the grass being cut, the bottom part of the garden fenced off, and some pleasant features including a herb garden and two swinging seats for the enjoyment of residents. The lovely Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 19 flowerpots to the front and rear of the property adds a colourful touch for residents and visitors to enjoy. However, some work is still to be done. The paving immediately in front of the house was not included in the replacement driveway and it is very uneven – the manager has removed some slabs, which moved from side to side, but this matter is outstanding from the last inspection and now needs some urgent attention. In one place the concrete was broken around a grid, which looked as if it could collapse – the manager placed a decorative flowerpot over this area to prevent people from walking directly across the grid. In addition, outside the home: • The porch support is cracked and needs to be replaced, and the underside of the porch has mould and damaged paintwork, which looks unsightly. Inside the home the following were also brought to the attention of the manager; • • • • • • • • Two upstairs window restrictors were broken (See Standard 42). An extractor was coming off the ceiling in one bathroom. The grouting carried out following the last inspection was not done to a high standard and already looks dirty and needs re-doing. Two bathrooms/toilets were not odour free – one is waiting to have a replacement floor covering; the other has no working extractor. The side of one bath needs repainting. Two bathroom light pulls were dirty and needed replacing. The decorating in a downstairs toilet is not to a good standard and should be reviewed. One resident had a broken drawer; the paint around the handles on the under-sink cupboard were all scratched; there was a large crack in the door; and the only chair in the room looked uncomfortable and was not a properly upholstered armchair. The blind was down in one bathroom and another had no lampshade. • As noted at the last inspection the home was generally clean and tidy. The laundry room, which is kept locked, was clean and well managed. There is a commercial washing machine with a sluicing facility, and one tumble dryer. There are also washing lines in the garden for airing laundry. There were good hand washing facilities throughout the home and the manager said residents are given a fresh towel every day in their rooms. However, with not all parts of the home being odour free as listed above, more work needs to be done to meet this Standard in full. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent staff but more work needs to be done with regard to staff qualifications. Recruitment practices are good, and arrangements for training means residents are supported by appropriately trained staff. EVIDENCE: Staff were observed to work well with residents and in particular to communicate well with them. Residents were seen to turn to staff for assistance and guidance throughout the day. Arrangements for equality and diversity are excellent and the home has a cultural assessment on file for each resident whereby every aspect of their cultural needs have been assessed. This is not only for residents from minority ethnic backgrounds, but for all residents. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 21 However, more work is needed on staff qualifications as currently less than 50 of care staff hold an NVQ qualification and this Standard sets down 50 as a target which should have been met by 2005. This was discussed with the manager and service manager who said progress was being made to meet this target. Arrangements for recruitment are robust and all staff at this home have the correct employment checks in place. An arrangement has been made with CSCI and Avenues Trust that a proforma documenting the checks carried out, and signed by the HR manager, is kept at the home for checking during an inspection. If there are any issues of concern, CSCI can ask for the documents to be brought to the home; this was not necessary on this occasion. Most staff CRB certificates were kept at the home. The manager was asked to review this, and whether some of these checks needed to be repeated as they were done some years ago. The CRB website gives guidance on how to store CRBs, how long to keep them for, and how often they should be renewed. A recommendation will be made in this regard at the end of this report. Staff training records at this home are very well kept. There is a central list of all mandatory training which means it is easy to see, at a glance, which staff have done which training courses, and when their refresher courses are due. All staff have done all the mandatory courses including protection of vulnerable adults, first aid, health and safety and the management of aggression. A training needs assessment is done through staff supervision and two staff files sampled showed they have regular supervision sessions. The staff all have a staff handbook to give them guidance in their roles and outline HR procedures. The home has just introduced the Common Induction Standards which will start this month for all new staff. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40 and 42 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well run home and there are sufficient quality assurance measures in place. More work needs to be done on policies and procedures, and on health and safety arrangements at the home. EVIDENCE: The registered manager has been at this home for 6 years. She has the Registered Manager’s Award and an NVQ4 in Care and Management. She regularly up-dates her own training and within the last year has done medication training, fire safety training, and an Adult Protection course. She is responsible for the day-to-day management of the home including managing the budget for all household bills and staff costs. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 23 One relative who responded on a comment card to CSCI said that they had always been delighted with the way Kenilworth is run and ‘The managerial side of the home is first-rate.’ There is a quality assurance policy for the service which sets out arrangements for monitoring the quality of the service provided, including getting feedback from residents and other stakeholders. There is an annual quality assurance cycle for staff and managers and a business plan is in place. The resident’s questionnaires are in a user-friendly pictorial format and they now have regular monthly resident’s meetings. Resident’s files contain details of ‘opportunity sessions’ they have taken part in where they can try new things to establish if they have any other interests or preferences – for example one resident had taken part in a music session and a food tasting session. A number of policies and procedures were sampled and found to be satisfactory but staff do not currently have access to up-to-date copies of policies and procedures. The system whereby Avenues Trust disseminate new policies and procedures electronically is not working well at this home, one contributing factor being the problems with the computer and printer at the home. Some policies and procedures on file were not the most recent and this was discussed with the manager and service manager who said they would ensure the latest versions were available in the office for staff to access. Arrangements for health and safety have improved since the last inspection and the majority of the Requirements have either been met or partially met – these are detailed at the beginning of this report. There are number of procedures and practices at this home which promote the health and safety of both residents and staff, for example there is a monthly health and safety check carried out by the designated health and safety representative for the home. Hand washing facilities are good and resident’s towels are changed daily; water outlets are thermostatically controlled to prevent scalding and these temperatures are monitored; and all radiators have safety covers. The environmental health officer visited in 2003 and the home scored sufficiently well that a further visited was not required for three years. However, there were a number of shortfalls on the day of the inspection. An Immediate Requirement was made regarding the window restrictors in one upstairs bedroom which were not working – the maintenance man was called straightaway and these were repaired within a couple of hours. A risk assessment should be carried out, and further advice sought from the environmental health department on the type of window restrictors being used and consideration given to whether these are sufficiently robust considering the present group of residents. Alternative or additional measures may need to be taken. Existing restrictors need regular monitoring to ensure they are working correctly. The risk assessment should include windows on the ground floor, which do not have restrictors, particularly at the front of the property where there is direct access to the road. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 24 Two other risk assessments must be carried out regarding; • Toiletries stored under the basins in resident’s bathrooms. • The uneven pathway to the front of the property, including the surround on the drain cover which is disintegrating. Arrangements for legionella prevention at the home must be reviewed. The Health and Safety Executive recommends a risk assessment being carried out and monitoring of the various identified risks, e.g. recording actual water temperatures, flushing out unused showerheads etc. Some steps have been taken but more work is needed, and advice should be sought from either the environmental health officer or from the Health and Safety Executive website. The environmental health officer’s visit is overdue and the manager should chase this up. In addition to specific advice on the window restrictors outlined above, the manager should also seek advice about their current practice of keeping one freezer in the laundry room. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 25 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 2 X 2 X Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 26 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 Timescale for action 09/08/07 2. YA24 Advice must be sought from the GP to ensure all ‘as required’ medication is documented as such on the medication administration records. There must be written guidance, signed off by the prescriber, for staff, regarding the circumstances when ‘as required’ medication is to be given. Consent must be obtained regarding the covert administration of medication to one resident, as set out under Standard 20 of this report. 13(4)(a)(b)(c) The whole of the paved area 23(2)(o) to the front of the property, (including the deteriorating drain cover), must be repaired or replaced so that it does not present a risk to service users or visitors. The driveway being repaired has partially met the previous Requirement from 02/08/06 23(2)(o) The following shortfalls, highlighted under Standard DS0000013689.V345647.R01.S.doc 16/08/07 3. YA24 09/08/07 Kenilworth (Horley) Version 5.2 Page 27 24 must be reviewed, and timescales sent to CSCI regarding when they will be remedied; • The porch support is cracked and needs to be replaced, and the underside of the porch has mould and damaged paintwork, which looks unsightly. • Two bathrooms/toilets were not odour free – one is waiting to have a replacement floor covering; the other has no working extractor. 4. YA42 13(4)(a)(b)(c) Some risk assessments 16/07/07 regarding toiletries have been carried out since the last inspection, but risk assessments must be carried out on all areas of the home where toiletries are kept. This must include in resident’s own bedrooms. The risk assessments and actions to minimise the risk must be documented. Partially met from 09/06/06 13(4)(a)(b)(c) A risk assessment should be 09/08/07 carried out, and further advice sought from the environmental health department, regarding the type of window restrictors being used, as detailed under Standard 42 of this report. Alternative or additional measures may need to be taken. The risk assessment should include arrangements for windows on the ground floor. Existing restrictors must be regularly checked to ensure they are working DS0000013689.V345647.R01.S.doc Version 5.2 Page 28 5. YA42 Kenilworth (Horley) correctly. 6. YA42 13(4)(a)(b)(c) Arrangements for legionella prevention at the home must be reviewed. Some steps have been taken but more work is needed, and advice should be sought from either the environmental health officer or from the Health and Safety Executive website. 09/08/07 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. Refer to Standard YA7 Good Practice Recommendations Advocates should be found for those residents with limited, or no family contact. Alternatives should be explored where applications are unsuccessful. (Carried forward from the previous three inspections). A number of shortfalls concerning the environment at the home need attention: The grouting carried out following the last inspection was not done to a high standard and already looks dirty and needs re-doing. • The side of one bath needs repainting. • Two bathroom light pulls were dirty and needed replacing. • The decorating in a downstairs toilet is not to a good standard and should be reviewed. • One resident had a broken drawer; the paint around the handles on the under-sink cupboard were all scratched; there was a large crack in the door; and the only chair in the room looked uncomfortable and was not a properly upholstered armchair-a new one should be chosen, in consultation with the resident, and purchased by the home. • The blind was down in one bathroom and another bathroom had no lampshade. Advice and guidance should be sought from the CRB website regarding how to store CRBs, how long to keep them for, and how often they should be renewed. DS0000013689.V345647.R01.S.doc Version 5.2 Page 29 2. YA24 • 3. YA34 Kenilworth (Horley) 4. YA42 The environmental health officer’s visit is overdue and the manager should chase this up. In addition to specific advice on the window restrictors outlined above, the manager should also seek advice about their current practice of keeping one freezer in the laundry room. Kenilworth (Horley) DS0000013689.V345647.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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