Inspection on 30/11/07 for Kenilworth (Banstead)

This inspection was carried out on 30th November 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 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) 17/08/06

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 30th November 2007 09:15 Kenilworth (Banstead) DS0000013690.V355048.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.V355048.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.V355048.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.V355048.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 17th August 2006 Brief Description of the Service: Kenilworth is owned and run by Mr and Mrs Wijewardena. It is a detached property within walking distance of the village of Banstead Surrey. 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. Fees range £980.00 to £1,050.00 Kenilworth (Banstead) DS0000013690.V355048.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 key inspection site visit, Mr. Kenneth Dunn, Regulation Inspector, undertook the site visit on behalf of the CSCI. The responsible individual represented the establishment. A full tour of the premises took place. Discussions with people who use the service or residents and staff were held informally and formally to canvass their experiences of the home. An annual quality assurance assessment (AQAA) was supplied to the home by CSCI, and this was completed and returned. Information from the AQAA will be referred to in this report. The AQAA states that the home has policies and procedures to promote equality and diversity and all staff have received training, to increase their knowledge and awareness of these issues. The final report takes into account detailed information provided by the registered provider, Annual Quality Assurance Assessment (AQAA), returned surveys (next of kin, medical professionals, care manger and any other interested representatives of the residents) in addition any information that the CSCI has received about the service since the last inspection will also be used to complete this report. The Commission for Social Care Inspection would like to thank the residents, relatives, management and staff for their hospitality, assistance and cooperation with this inspection. What the service does well: The location of this home well situated for ease of access to the wider community and is ideally suited for its stated purpose. There are homely and family touches throughout the home. The social, health and personal care needs of the residents are well addressed, and there is input from a range of healthcare professionals and other specialists as required. The residents are fully supported in accessing the community and the staff and manager go to great lengths to ensure that they play a role in the life of the village and their places of work. Overall, there was a high level of commitment to ensuring that the lifestyles of the residents was maximised and that they were fully supported in their decision making. The home set great store by supporting the residents to live their lives in an environment of respect, dignity and individuals’ aspirations. Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 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.V355048.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standard 2 was assessed during this visit. This judgement has been made using available evidence including a visit to this service. The home’s procedure of carrying out detailed assessments and offering visits prior to admission, enable residents and prospective residents to make an informed choice about the home. EVIDENCE: There has been no new residents admitted to Kenilworth since the previous site visit, the last person to move into the home was over three years ago. The home has a robust policy on assessing the needs of all potential residents and the impact they could potentially have on the existing residents. The registered provider informed the inspector that all potential residents would only be admitted to the home following a full assessment of their needs and that they would encourage the person to visit the home on frequent occasions. A review of all three residents files indicated that their needs had been fully assessed and this information formed the bases for their care plans. Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good Standards 6, 7and 9 were assessed during this visit. This judgement has been made using available evidence including a visit to this service. The residents are involved in the decisions making process about their lives; they are supported to participate in planning the care and support they receive. EVIDENCE: The care plans are person-centred and designed to enable the needs of the residents to be effectively met. The plans outline the health, personal and social care needs to be addressed and offers an individualised programmes of activities. Where limitations are recognised, there are documented risk assessments in place covering the individual, the activities, the environments and details the roles and responsibilities of the staff in minimising the risk. The plans focus on how the resident can develop their skills and interests, and details the levels of support the staff are required to offer in order to effectively support the individual, within the home and outside of the care Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 10 environment in order to allow them to led as independent a lifestyle as possible. A sample of care plans confirmed that they are reviewed regularly as routine. The responsible individual stated that in addition to the planned reviews the home would review the plans in order to respond to any changes in the resident’s needs and behaviour. Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is good. Standards 12, 13, 15, 16, and 17 were assessed during this visit. This judgement has been made using available evidence including a visit to this service. The resident’s benefit from the support they receive in order to enable them to make choices about their life style, and to develop their life skills. The residents participate in social, educational, cultural and recreational activities that benefit their individual needs and aspirations. EVIDENCE: The home offers the residents individualised levels of support in order to maintain and develop appropriate life skills, all three residents participate to the best of their abilities in housework and they are all employed by community operated or private organisations within the Banstead area. Two residents work in the kitchen of a local hotel and day centre for older people and one work in a local community based garden centre. The residents Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 12 are all very proud of their work and have informed the inspector that they get a great deal out of working and meeting new people. A random sample of residents care plans provided evidence that activities are, in each case, properly underpinned by a comprehensive range of risk assessments and specialist input as appropriate. The Responsible individual informed the inspector that the home maintains records of all the activities the residents engage in to ensure that they continue to benefit for their participation. The resident are supported to access the local community whenever they want and two of the residents especially enjoy shopping or just window shopping in Banstead village or in Epsom. The inspector was informed by the responsible individual that the home has its own transport to ensure that the residents can access the community as often as they want. The home organises annual holidays for the residents the inspector was informed that this year they two of the residents went with staff for a holiday in Majorca, while the third resident decided to have a holiday with a friend here in the UK. There is evidence of the support the staff give to ensure that the residents can have as full and appropriate contact with their friends and families both locally and further a field. Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is good Standards 18, 19 and 20 were assessed during this visit. This judgement has been made using available evidence including a visit to this service. The health and personal care that the residents receive is based on their individual needs. The principles of respect, dignity and privacy are core elements of the care provided by the home. EVIDENCE: The home’s person-centred care planning processes ensure that the individual residents receive the appropriate levels of assistance that they require, in respect of their personal care. The inspector was informed that as part of the care process the residents are actively encouraged to have choice and control over how much support they may or may not need, however the ultimate level has been set within a multi disciplinary environment in order to maintain an appropriate level of care. A “Health Action Plan” has been developed for each of the residents. A review of the resident’s files demonstrated that they are all in receipt of a full range of community based health care and that they are all registered with a local GP. Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good Standards 22 and 23 were assessed during this visit. This judgement has been made using available evidence including a visit to this service. The residents are supported to express opinions and raise issue appropriately. The complaints procedure is accessible to the residents. The residents are protected from abuse, and have their rights protected. 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 since the previous inspection visit and a review of the complaints log would indicate that there have been no complaints made to the management of the home. The residents have alternative opportunities available to them in the event that they want to make a complaint about the home or about staff. The inspector was informed that two of the residents have friends and work colleagues who they could and would talk to if they felt that they were being unfairly dealt with or that someone was abusing them, a third resident has limited verbal communication, the responsible individual stated that he could however communicate to others if he wanted to raise an issue. The home has an up to date copy of the local Surrey County Council Multi Agency Safeguarding Adults Policy and staff have had some training in respect of the protection of vulnerable adults. Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. Standards 24 and 30 were assessed during this visit. This judgement has been made using available evidence including a visit to this service. The physical environment of the home matched the needs of the residents and in accordance with the statement of purpose. Attention was required to general maintenance of the décor in some areas and furnishings and to odour control. EVIDENCE: Generally the home is clean and meets the needs of the residents, there is a need for the home to develop a rolling plan if decoration and maintaince in order to improve and maintain the environment. The communal areas, two sitting rooms and the kitchen of this home are of a reasonable size. The seating in the dining and sitting rooms are appropriate for the resident’s. However the continuing use of one of the sitting rooms as a smoking room for two of the residents requires the management of the home to review the ventilation of the ground floor. Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 16 The kitchen is light; airy, clean and relatively well maintained the exception was a large burn mark on the work surface next to the hob where a hot item had been set down. The responsible individual has developed a plan for the deep cleaning and redececoration of the home. The inspector was informed that this would include the cleaning of all carpets to remove heavy stains, which will then be followed by the redecoration of a major proportion of the home. The inspector was informed that all internal cleaning and decorations would be completed by the end of February 2008. The day-to-day cleaning of individual residents bedrooms is the responsibility of the person occupying the room the staff encourage them to undertake this task without assistance. However the staff will intervene and work with the individual residents if their rooms become untidy or if the develop a strong odour as they were on the day of the visit. The inspector was informed that the staff will offer to assist in the process of cleaning, but at the same time they are very conscience of the residents rights to privacy and dignity so therefore they do not go in without an agreement from the individual. Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is adequate. Standards 32, 34, 35 and 36 were assessed during this visit. This judgement has been made using available evidence including a visit to this service. The resident’s benefit from a competent and stable staff group. The home has a recruitment policy unfortunately it is not followed. Some staff training is undertaken. Staff supervision does not appear to be offered. EVIDENCE: The residents are supported to a very high degree by a group of people who have been with the home for some considerable time. There is evidence that the staff team and the residents work well as a team and the home benefits as a whole from this stability. The inspector audited all staff files and found that there were considerable gaps in every area of the files. The home had failed to meet a requirement to ensure that all staff files contain all relevant information set out in Schedule 2 of the Care Homes Regulations act 2001 please refer to page 23 of this report. In addition staff have not received appropriate supervision again in direct contravention of the Care Homes Regulations act 2001 and was also subject to Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 18 a requirement from the previous report dated 17/08/2006 please refer to page 24 of this report. Therefore these requirement still stand and new dates for the home to comply have been set. The registered manager and responsible individual must understand that a failure to comply with these may result in CSCI seeking legal advice, if these continue to remain unmet. Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. Standards 37, 39, 41 and 42 were assessed during this visit. This judgement has been made using available evidence including a visit to this service. The residents benefit from the management of the home, which is based upon openness, respect, dignity stability and for its service objectives. The lack of self-auditing and a failure to comply with previous requirements has had a detrimental effect on overall management of the home. EVIDENCE: The responsible individual informed the inspector “Kenilworth is a home that is dedicated to ensuring that the people who live there receive a service, which is totally user focussed”. There is good documented evidence of teamwork between staff and residents working together and making this service a home. Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 20 The friendly family atmosphere, which exists at the home, allows the residents to feel “secure and part of a family”. The dignity and respect shown towards the residents was well documented and demonstrated during the site visit especially in the way the residents have the ability to make their own decisions. The inspector was informed that residents right are “core to the service”, however if the choices they may make could have possible detrimental effect on them or the home the manager and staff will work with the individual to achieve a more effective outcome. The home has not undertaken any form of self-monitoring. The responsible individual has developed a procedure in a resident focused format to undertake an audit of the home and the service it provides but this has still not been undertaken. This is the second time the home has failed to complete the selfmonitoring process, they were required to do by the previous inspection report dated 17/08/2006. However the residents have a good network of family, friends, care professionals and work colleagues that they are more than willing to go to if they felt a need to discuss the home or a problem they may be having with someone or some aspect of the home. As was previously sated on pages 19 & 20 of this report the record keeping and the implementation of policies and procedures especially in respect of staffing and recruitment have not been put into practices. It is essential that the registered provider ensure that all the residents a fully protected by the implementation and the continual use of appropriate record keeping and management. The inspector was informed that the health and safety of the residents is seen as a high priority for the home. The manager conducts regular check throughout the home to ensure that the residents and staff work and live in a safe environment. The responsible individual unfortunately could not locate this information during this site visit and therefore a requirement has been. Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 21 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 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 2 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 2 X 2 2 X Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation 19 Schedule 4.6 Requirement 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. Previous requirement 17/08/06 not met. Timescale for action 24/12/07 2. YA36 18(2) All Staff must receive supervision 24/12/07 as per the requirements stated within the National Minimum Standards. Previous requirement 17/08/06 not met. 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. Previous requirement 31/08/06 not met. The responsible individual must ensure that all records required DS0000013690.V355048.R01.S.doc 3. YA39 24 24/12/07 4. YA41 17 Schedules 24/12/07 Kenilworth (Banstead) Version 5.2 Page 23 3&4 by regulation for the protection of the residents and for the effective running of the business are maintained, accurate and available for the purpose of inspection by a CSCI representative. 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.V355048.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office 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. Extracts may not be used or reproduced without the express permission of CSCI Kenilworth (Banstead) DS0000013690.V355048.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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