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Inspection on 10/11/05 for Kenilworth (Banstead)

Also see our care home review for Kenilworth (Banstead) for more information

This inspection was carried out on 10th November 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There is evidence of the hard work and dedication of the staff to ensuring the resident`s needs are assessed and that their care needs are planned and met in the way they prefer. This was fully substantiated by comments made by the residents during the inspection and from feedback cards received from relatives of the residents and from professional visiting the home on a regular bases.

What has improved since the last inspection?

The previous inspection was positive the requirements that were made at that time had all been adopted and now form part of the homes basic procedures. The service appears to continue to offer the same high level of care as it had previously.

What the care home could do better:

The home must continue to offer a safe and secure environment for the residents to live in and allow them to feel part of a unified community.

CARE HOME ADULTS 18-65 Kenilworth (Banstead) Kenilworth (Banstead) 74 Diceland Road Banstead Surrey SM7 2ET Lead Inspector Kenneth Dunn Announced Inspection 10th November 2005 09:00 Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kenilworth (Banstead) Address Kenilworth (Banstead) 74 Diceland Road Banstead Surrey SM7 2ET 01737 361858 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) Mr Gamini Wijewardena Mrs Balapuwaduge Wijewardena Mrs Balapuwaduge Wijewardena Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range is 45 - 64 years of age for all 3 residents. Date of last inspection 26th April 2005 Brief Description of the Service: Kenilworth is owned and run by Mr and Mrs Wijewardena It is a large detached property within walking distance of Banstead town. The accomodation covers two floors and provides care and services to three service users (residents) with learning disabilities. Each resident has their own single bedroom one of which has an ensuite facility. There are two lounge areas, a dining/kitchen area and an office on the ground floor. There is a private secluded garden with patio area and car port to the rear of the garden. There are local amenities nearby. The home also provides transport to the residents if they do not choose to use public transport. Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection that has taken place this year 2005/2006. The inspection was announced and therefore the residents and staff were aware that the inspector was visiting. The residents made a specific request of the inspector to ensure that they are called residents, as they do not like being referred to as service users or clients. The manager was present throughout the inspection and the inspector was given plenty of opportunity to speak to the residents and staff who were on duty. Records were also seen. The atmosphere in the home was relaxed. Residents were freely accessing many different areas of the home. The home was clean and tidy and there were adequate staff on duty. The inspector wishes to thank all those involved in providing the information in this report and in particular the residents, the relatives/friends, the manager/ the provider and the staff present. What the service does well: What has improved since the last inspection? What they could do better: The home must continue to offer a safe and secure environment for the residents to live in and allow them to feel part of a unified community. Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 6 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. Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The information available to prospective residents and or their representative would provide a full and accurate picture of the service allowing them to make an informed choice about the home. EVIDENCE: No new clients have moved into the home since the last inspection 26 April 2005. In line with a requirement made during the previous inspection the manager has developed and enhanced the statement of purpose. The document now in operation would allow prospective residents with sufficient up to date information to make an informed choice as to the appropriateness of Kenilworth in meeting their needs. It is recommended that the manager ensure that all reviews have an introduction date and a projected review date at the foot of each of the services policy documents. Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 & 10 The home continues to meet the individual needs and choices of the residents. EVIDENCE: In line with a requirement from the previous inspection all of the care plans and assessments audited during this visit have been updated and reviewed by the staff and the residents. The residents who are able to have, signed or made their mark to indicate that they have participated in the review and agreed with the plans. The plans were current and substantiated the general comments made to the inspector by the residents throughout the inspection. All of the residents spoken to during the inspection informed the inspector that they were very well looked after and the staff supported their individual needs. The service has reviewed the policy of confidentiality and it now clearly states that all documents belong to the service and the individual residents and must not be removed from the premises, to maintain their confidentiality and security. It is recommended that the manager include an explanation of the services confidentiality policy within the statement of purpose and residents guide. Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11, 12, 13, 14, 15, 16 & 17 were assessed on the last inspection. EVIDENCE: For information on these standards please refer to the report dated the 26th of April 2005. Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The service has a comprehensive set of policies and procedures for the guidance of care staff. EVIDENCE: The policies and procedures were found to comply with guidelines established by the National Minimum Standards. All residents are risk assessed to establish their suitability to retain and administer their own medications. At the time of this inspection no resident of Kenilworth was self-medicating they all depended upon the assistance of staff. There was clear documented evidence as to the various degrees of assistance offered to individuals within the home in respect to administration of medication two residents required only limited assistance while one other depended upon staff to a greater extent. Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 All required policies and procedures are in place to ensure that service users are safeguarded from harm or abuse. EVIDENCE: CSCI have received no complaints about this home. The manager has completed a review of the services complaints policies in line with two requirements made during the previous inspection report. The inspector was informed that all members of staff have now received training in the protection of vulnerable adults. Although Kenilworth appeared to be a very harmonise home and the residents were happy to chat and discuss issuses with the inspector and assured him that they were very able to go to the staff and complain. The residents explained that the staff act promptly to resolve any issues or complaints they may have and on the whole they are very happy with the actions they take. However upon revieweing the complaints log it was appartent that the staff were only recording complaints or issues that they felt merited being noted. It is therefore a recommendation that the manager develops a policy whereby all issuse no matter how trivial they may appear are recorded appropreatly in the complaints log. It is further recommended that there should only be one log for the service to avoid duplication and confusion when a complaint is being recorded. Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 29 & 30 were assessed on the last inspection. EVIDENCE: For information on these standards please refer to the report dated the 26th of April 2005. Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 Staff in the home have a good understanding of the needs of the Service Users and are appropriately supported by the manager. EVIDENCE: In line with the requirements made during the previous inspection the Registered Manager now ensures that all pre employment checks are carried out prior to staff commencing employment at the home. It is recommended that in order to ensure that this policy operates in accordance with the homes new employment procedures, the manager should develop a check list of all essential items required to ensure the residents are protected and safeguarded, the list should include the dates the manager receives clear CRB and POVA checks, two references, completed application form and any other relevant items deemed essential by the home in order to protect the residents. The service has developed a comprehensive training matrix in to ensure that all staff receive sufficient training to meet the needs of the residents. The inspector was informed by the manager that this process has not been fully completed but that it was hope that all staff would have completed essential core training by the end of 2005. Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 & 42 Quality audits are not given a priority There were no health and safety issues relating to the home. Relevant checks were done and the home was maintained safe. EVIDENCE: The service holds regular health and safety checks and provides training in all aspects of health and safety. The policies and procedures in operation comply with National Minimum Requirements. Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 16 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 1 X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kenilworth (Banstead) Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 3 X DS0000013690.V259610.R01.S.doc Version 5.0 Page 17 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. Standard Regulation Requirement Timescale for action 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 4 Refer to Standard YA1 YA10 YA22 YA23 Good Practice Recommendations It is recommended that the manager ensure that all policy reviews have an introduction date and a projected date at the foot of each of the services policy documents. It is recommended that the manager include an explanation of the services confidentiality policy within the statement of purpose and residents guide. The manager should develops a policy whereby all issues no matter how trivial they may appear are recorded appropriately in the complaints log. It is recommended that there should only be one complaints log for the service to avoid duplication and confusion when a complaint is being recorded. Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Kenilworth (Banstead) DS0000013690.V259610.R01.S.doc Version 5.0 Page 19 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!