Inspection on 17/08/06 for Kenilworth (Banstead)

This inspection was carried out on 17th August 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kenilworth (Banstead) 26/11/08

Kenilworth (Banstead) 30/11/07

Kenilworth (Banstead) 10/11/05

Kenilworth (Banstead) 26/04/05

Kenilworth (Banstead) 17/12/04

Kenilworth (Banstead) 27/07/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

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 (Banstead) Kenilworth (Banstead) 74 Diceland Road Banstead Surrey SM7 2ET Lead Inspector Kenneth Dunn Unannounced Inspection 17th August 2006 10:00 Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kenilworth (Banstead) DS0000013690.V302176.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 (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 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.V302176.R01.S.doc Version 5.2 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 10th November 2005 Brief Description of the Service: Kenilworth is owned and run by Mr and Mrs Wijewardena It is a detached property within walking distance of Banstead town. The accommodation covers two floors and provides care and services to three service users (residents) with learning disabilities. Each resident has his or her 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 carport 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.V302176.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector over a period of 5 hours. A partial tour of the premises took place, staff and service users were spoken to, and care records and documents were inspected. On the day of the inspection the manager was off duty and the inspection was facilitated by a member of the care staff and the Responsible Individual (RI) who have a knowledge and understanding of how the home operated. The inspector would like to thank the staff on duty and service users for their contributions to the inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 Page 6 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.V302176.R01.S.doc Version 5.2 Page 7 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is evidence that the home undertook detailed assessments of the service users who live at the service prior to their admission and that staff have a good understanding of their individual and group needs. EVIDENCE: All three service users have lived in the home for more than a year and the staff work continually to ensure that there individual and group needs are consistently met. This was very evident from talking to the service users at home during the inspection. One service user was delighted to inform the inspector of the care they all received from the staff was very good the staff and the manager are “caring” and assist the service users to access the local community as often as they want. Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is offered to the service users in a way that fully promotes their independence and allows making informed decisions about their lives. EVIDENCE: Staff stated that residents are supported to make decisions affecting their lives in a number of ways. It was stated by the Responsible Individual (RI) that all staff are trained to offer one to one support to the service users. One service users stated that the she trust the staff they know and understand her and this helps her “cope with her life inside and outside of the home. The manager holds regular monthly house meetings they are held to enable service users to make decisions and choices examples being holidays planning, menus and outings. One service user expressed great pleasure about the homes forth coming annual holiday to Spain. The service users explained how the manager has organised the holiday and all 3 service users and 3 members of staff go off for “a holiday together in the sun”. Staff advised the inspector that information is provided to the service users to assist them with decision-making and this is in a format to suit their individual Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 Page 9 needs. It was explained to the inspector by the RI that the staff team ensure the service users are verbally informed of their rights and this is in conjunction with the written documents that are supplied to them. The manager conducts risk assessments on all activities. Risk assessments are completed and contained within the individual service users files. Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 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): 12, 13 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good rapport between service users and staff. There is clear evidence that the staff group encourage the service users to embrace opportunities for social and personal development. EVIDENCE: Service users stated that they are all actively encouraged and supported by the staff to be independent and to make their own choices and to live their lives as they wish, as far as they are able. It was stated by a member of staff that the service users have strong links with friends in the local community and are assisted if necessary to maintain these links. One of the service users was able to explain to the inspector her very active and busy social life and thanked the staff and the manager for supporting her to maintain these important licks in her life. The service users were also looking forward to the homes annual holiday in Spain. Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 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): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are able to make choices and decisions about the way they are supported and cared for by the home’s staff. The systems in place for the administration and control of service users medication are only satisfactory. EVIDENCE: Service users care plans, conversations with service users, staff and the responsible individual demonstrated that the residents are able to make choices about how they spend their days and that they are helped to be as independent as possible. The service users medication is securely stored and the duty member of staff holds the key. The Medication Administration Record (MAR) sheets were seen and gaps in the recording were noted. The inspector was informed that the MAR sheets have to be regularly altered when they arrive from the pharmacy because of inaccuracies on the sheets, however there was no explanation as to why the changes were being made and the sheets became unclear and confused. The MAR sheets must not be altered without clear information as to why they have been altered and if a regular problem is identified the manager must ensure that appropriate remedies are sought. In addition the MAR sheets were found to have several inaccuracies and staff did not always complete sections. The MAR sheets must be fully completed ensuring that no gaps are Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 Page 12 left, where there is a problem these must be fully documented and detailed on the sheet. No service users self medicates the manager has completed risk assessment to support this. Service users were registered with a general practitioner (GP). In partnership with the CPN the home has developed health action plans for all the service users. Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complains system and there is evidence that the service users feel their views are listened to and acted upon. EVIDENCE: The service has a complaints policy, which is contained within the Service User guide and the employee’s handbook. There have been no complaints made directly to the CSCI and a review of the complaints log would indicate that there have been no complaints made to the manager since the previous inspection. The service users informed the inspector that they were more than happy with the home and have not had to make any complaints. One service users felt that if she had an issue with anyone she could go to the manager, her care manager, friends out-with the home or her employers she felt that this situation was the same for all the service users and that they all have several outlets to complain if they have issues. Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are clean and provide the service users with homely and comfortable rooms that are satisfactory and meet they’re individual and joint needs. EVIDENCE: A partial tour of the home was done as two service users had gone out and were unavailable to ask permission to visit their bedrooms. The home was very clean throughout. One service users stated that she liked her bedroom and the fact that she can have all her own furniture and passions around her. However the general condition of decoration on the first floor of the home was showing signs of ware with missing strips of ceiling paper and poor paintwork identified in on bedroom in addition there was broken items of furniture found in the same bedroom. The responsible individual ensured that they had been removed prior to the completion of the inspection. It is essential that the manager keep the home freshly decorated to continue to meet the needs of the service users. The manager must therefore develop a work plan for the redecoration to start and a projected completion date. Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 Page 15 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): 32, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users are supported and assisted by experienced and competent staff. However there is confusion within the homes recruitment policies and essential check have not been undertaken. The policy for staff supervision did not meet the National Minimum Standards. EVIDENCE: The service users benefit from a very stable and experienced staff group who have developed a good working relationship with the residents over a number of years, and this has to be commended. Staff were seen to interact appropriately and effectively with the service users. The service users stated that they felt fully supported by the staff. The staff group genuinely seemed intent on empowering the service users to access the wider environment and to make decision for themselves. However the inspector sampled 4 staff member’s files and found them to be unsatisfactory. For example the service has failed to make enquiries to ascertain if the any members of staff have been referred to the POVA list (Protection Of Vulnerable Adults) and there was little evidence of supervision being undertaken by the manager, one member of staff had not received supervision since August 2005. The manager must ensure that all checks a completed on all staff members The manager must ensure that all staff files contain all relevant information set out in Schedule 2 of the Care Homes Regulations 2001. Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 Page 16 All staff must receive supervision must be completed as per the requirements stated within the National Minimum Standards. Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good supportive “family atmosphere” in this home that is a result of the commitment and support given by the manager and her staff towards the service users and each other. EVIDENCE: The manager has experience of supporting people with a learning disability and has worked within this field for over 32 years. The home had a policy on Quality Assurance (QA) and has developed questionnaires to obtain feedback about the home, however the inspector was not in apposition to review the results and it was unclear when the last questionnaire was completed. The manager must ensure that a QA questionnaire is distributed to all relevant parties and especially to the service users, this must be on a regular bases and in line with the National Minimum Standards. Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 Page 18 It was however pleasing to note that in talking to the service users and observing staff interacting with the service users it was apparent that the service users felt confident that the staff listen to, and acted upon, their views about the home and any individual worries. The service users are consulted daily about their preferences and to what extent they want to join in with planned events or social activities. One service users stated that if she did not want to be part of the group she could just go off to her bedroom and do her “own thing” there was no pressure from the staff. Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 Page 19 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 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 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 3 X 3 X X X X 3 X Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 Page 20 NO 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 12(1,4) 37, Schedules 3.3 (g,k,q) 12(1,4) 37, Schedules 3.3 (g,k,q) 16(1), 23(1,2) Requirement The MAR sheets must not be altered without clear information as to why they have been altered. The MAR sheets must be fully completed ensuring that no gaps are left, where there is a problem these must be fully documented and detailed on the sheet. Timescale for action 17/08/06 2 YA20 17/08/06 3 YA24 The manager must ensure that a 30/09/06 programme of refurbishment and redecoration is actioned to ensure that the home meets the National Minimum standards. The manager must ensure that 17/08/06 all checks a completed on all staff members. The manager must ensure that all staff files contain all relevant information set out in Schedule 2 of the Care Homes Regulations 2001. All Staff must receive supervision 17/08/06 as per the requirements stated within the National Minimum Standards. The manager must ensure that a 31/08/06 DS0000013690.V302176.R01.S.doc Version 5.2 Page 21 3 YA34 19 Schedule 4.6 4 YA36 18(2) 5 YA39 24 Kenilworth (Banstead) QA questionnaire is distributed to all relevant parties and especially to the service users, this must be on a regular bases and in line with the National Minimum Standards. 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 Kenilworth (Banstead) DS0000013690.V302176.R01.S.doc Version 5.2 Page 22 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.V302176.R01.S.doc Version 5.2 Page 23 - 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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