Inspection on 01/08/07 for Kenilworth Care Home

This inspection was carried out on 1st August 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 but made no statutory requirements on the home.

Other inspections for this house

Kenilworth Care Home 21/07/09

Kenilworth Care Home 03/08/06

Kenilworth Care Home 21/12/05

Kenilworth Care Home 20/04/05

Kenilworth Care Home 15/09/04

Kenilworth Care Home 21/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Kenilworth Care Home Duncan Place Loftus Saltburn TS13 4PR Lead Inspector Brenda Grant Key Unannounced Inspection 10:35 1st August 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kenilworth Care Home DS0000059126.V346825.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kenilworth Care Home Address Duncan Place Loftus Saltburn TS13 4PR 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) 01287 640203 F/P 01287 640203 Mr Sunny Okukpolor Humphreys Mrs Maureen Middleton Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The Manager (Maureen Middleton) should attain (by 2005) a qualification at Level 4 NVQ in Management and Care or equivalent. The Registered Provider (Mr Sonny Humphreys) must attain by 2006 a qualification at Level 4 NVQ in Care Management. The two outstanding requirements from the NCSC Inspection of 21.01.04 must be met within 3 months from the change of ownership. 3rd August 2006 Date of last inspection Brief Description of the Service: Kenilworth Care Home is a two storey Victorian House, with a purpose built, modern extension to the rear, which is situated in its own grounds, with a spacious garden, accessible to residents. There is a paved entrance to the rear and car parking adjacent to the entrance. The home provides accommodation for 20 older people, both male and female. Thirteen of the bedrooms are located on the ground floor, offering en-suite facilities of toilet and wash hand basin, and are well decorated. First floor bedrooms are accessed by the stairs and/or stair lift. The home has two lounges and a spacious entrance hall with seating, and the dining room is bright and spacious. The laundry is located in the basement. There is a telephone available for residents use, and the home has a no smoking policy. At the time of the inspection the minimum and maximum fees were £425.04. Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection. We assessed the information from: the Annual Quality Assurance Assessment and we carried out a visit to the home. The visit took place over one day, six hours twenty minutes in total. Discussion took place with: residents and their relatives, care staff, cook, provider, deputy manager and the manager. We looked around the home and examined a number of records that included; residents and staff files, health and safety and maintenance checks and complaints, accident and kitchen records. The findings from the inspection were of the home providing a good care service with most of the National Minimum Standards being met. What the service does well: Comments, from residents about the home included: “Everything is lovely.” “Staff are always friendly and willing to help.” “I couldn’t be anywhere better than here.” “I have a lovely view from my bedroom. It helps me to stay familiar with my surroundings.” The home provided a pleasant, comfortable and homely environment for the residents. The home had a stable staff group; many of the staff had worked at the home for a long time. The relationship between staff and residents was very relaxed and it was obvious that staff enjoyed their work. We saw staff being very gentle and considerate towards residents and staff made sure they had time to talk with residents. The manager made sure care staff spent ‘quality time’ with residents, at least on a weekly basis. That was when residents had the opportunity to have a one to one private talk with their Key Worker Resident’s rights were respected and residents lived their lives as they wished. Kenilworth Care Home DS0000059126.V346825.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 Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 3 & 6 Resident’s needs were assessed before moving to the home and they were assured those needs would be met. EVIDENCE: Residents who were funded by the local authority have assessments, carried out by a care manager and the assessments were shared with the home. For those and privately funded residents, the manager carried out a further assessment, so that Kenilworth Care Home could determine whether the person’s needs would be met at the home. The assessment included details of: health, social and personal needs as well as social interests, hobbies and religion. Two residents said, they were involved with the assessment process and members of their families had the opportunity to look around the home Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 9 before the resident was admitted. One resident said, “My daughter thought this was the nicest home she looked at”. The home did not offer intermediate care therefore standard six does not apply. Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 7, 8, 9 & 10 Resident’s health, personal and social care needs were fully met and recorded in Care Plans. Residents were protected by the home’s policies and procedures for dealing with medicines. Residents were treated with respect and their right to privacy was upheld. EVIDENCE: The home developed Care Plans for each resident. There was basic information about the person’s care needs and the plans were regularly reviewed. Three residents said, they were involved with reviews and residents or their relatives had signed the Care Plans, confirming they agreed with how care would be delivered. Care Plans included a statement of areas of risk and there were details for how those risks would be managed; to reduce risks to an acceptable level. Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 11 Resident’s files included healthcare information. The reader could easily see the regularity of visits for treatment from: GPs and District Nurses, opticians, chiropodists, dentists and other healthcare specialists. The details included the outcomes of the visits. The home took appropriate action for managing resident’s medicines. The storage and recording was found to be satisfactory. Resident’s files included assessment details for whether it was suitable for a resident to look after their own medicines. Staff files confirmed staff had completed training for safe handling of medicines. Staff were observed being respectful to residents and knocking on bedroom doors before entering the room. The relationship between staff and residents was very relaxed and residents spoken with confirmed they were treated with respect. All comments, from residents were very complimentary about how staff looked after residents. One resident said of the staff, “They are all lovely”. We noticed when staff assisted residents, with moving from lounge chairs to wheelchairs, how gentle staff treated residents; staff talked with residents and gave reassurance about what was happening. Good practice continued, when residents were being moved in their wheelchairs, all of the time staff spoke with residents; showing us that staff giving residents individual attention was important. Resident’s right to privacy was upheld and residents spoke with confirmed that was the case. There were no shared bedrooms thereby residents, previously in shared rooms, were allowed more privacy and their own personal space. Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 12, 13, 14 & 15 Residents lived their lives as they wished and residents maintained contacts with families and friends. Residents had choice and control over what they wanted to do. The home provided a varied and balanced diet. EVIDENCE: Staff said, the home tried make sure residents social, cultural and recreational interests were catered for. There was a programme of activities but the record did not show that many activities had taken place during July. Residents said, they enjoyed ‘quality time’ with staff; that was when resident’s nominated Key Workers spoke privately with residents. Quality time included asking residents what kind of activities they would wish to do, gain opinions from residents about the food offered to them or just to have a private talk. The home provided for resident’s religious needs; by arranging regular visits, at the home, from two different religious sects. The manager said, “If it was not provided for, the home would always make suitable arrangements to meet resident’s religious and cultural needs”. Staff said, they sometimes accompanied residents to go out for a walk. Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 13 Residents and staff said, relatives and friends were always made to feel welcome when they visited the home. Staff said, the home had regular contact with resident’s families. One the day of the inspection ‘site’ visit, some resident’s relatives were seen enjoying visiting a resident and one visitor said, “We are can come any time and the staff are always friendly”. Residents said, they felt they were in control of their lives and they lived their lives as they wished. One resident said, “We make our own decisions” and another resident said, “I can please myself with what I want to do”. Residents said, they were able to bring their personal possessions and have their bedrooms arranged as they wished. The home accommodated for residents who wanted to: get up early or late, stay in their bedrooms or go to communal rooms. The home’s menus were examined; they showed there was a variety of food offered to residents. The cook served the meat on plates, from the kitchen, but the vegetables were served from tureens that were placed on the tables. That allowed residents to choose the amount of food they wished to have on their plate. All residents spoken with said, the food was very good and one resident commented, “Food is delicious”. The food at the home was of there being fresh fruit and vegetables and a good variety other foods. The cook kept a record of the food that had been served to residents and there were completed records for: the cleaning rota, fridge, freezer and food temperatures. Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 16 & 18 Residents were confident their complaints would be listened to, taken seriously and acted upon. Residents were protected from abuse by the home’s policies and procedures. EVIDENCE: The home had a Complaints Procedure but it did not inform complainants they would receive a written response about a complaint. The information in the procedure did not include details of how to contact the local authority. Residents and a relative spoken with informed, they did not have anything to complain about but they were confident complaints would be appropriately dealt with. Since the last inspection the home had not received any complaints. The manager had six ‘thank you’ cards that complimented the manager and staff for the care they had given to residents. One card commented, “It (the home) is like a 5 star hotel”. The home had procedures for protecting residents from abuse. Staff records confirmed staff had completed training for safeguarding vulnerable adults. Staff said, they knew the procedures to follow if there was an allegation of abuse to a resident. Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 19 & 26 Residents lived in a safe and well-maintained environment. The home was clean, pleasant and hygienic and free from offensive odours. EVIDENCE: Kenilworth Care Home provided a homely and comfortable environment for residents. Wheelchair access in the home was limited, due to a narrow hallway but staff easily managed to assist residents, with moving around, that area of the home. The Annual Quality Assurance Assessment informed us and we saw that some of the carpets and furniture had been replaced. Additionally, the home had bought some new wardrobes that, the manager said, were to be erected during August 2007. Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 16 We saw that the home’s garden was well maintained. There was a grassed area with seating and the tall trees and hedging allowed for a private, shaded area for residents to enjoy the garden in warmer weather. The fencing and a handrail had been replaced, making it safer for residents when they were in the garden. The home’s maintenance records were examined. The requirements of the Environmental Health Department had been met. A senior carer was responsible for making sure all fire safety measures were in place. The records of fire safety checks included: fire alarm weekly tests that gave details of the fire point tested, fire training for staff, checks of equipment and assessing risk of fire in the building. The home was clean, pleasant, hygienic and free from offensive odours. There was a basic laundry facility; with washing and drying machines. The flooring and walls of the laundry had peeling paintwork and needed to be redecorated. Residents said, they were satisfied with how staff looked after their clothing and bedding. Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 27, 28,29 & 30 Resident’s needs were met by the numbers and skill mix of staff who were trained and competent to care for the residents at the home. Residents were protected by the home’s recruitment procedures. EVIDENCE: On the day of the inspection ‘site’ visit there was sufficient staff on duty to meet the needs of the residents presently living at the home. In addition to care staff there was two cooks and three domestic staff. One staff said, “We always work as a team”. The home had a stable staff group who had many years of experience caring for older people. Seven out of fifteen care staff had successfully completed the National Vocational Qualification at Level 2. The manager informed, there were three care staff nearing completion of the qualification. Staff’s training files confirmed staff had completed basic and further training. Some staff had completed extra training for caring of older people. Senior staff, who gave residents medicines, had completed training for safe handling of medicines. Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 18 Staff spoken with and staff files confirmed the home followed the recruitment procedure. Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 31, 33, 35 & 38 The home was well managed and run in the best interests of the residents. Residents were included with any developments and improvements that took place. Resident’s personal monies were safeguarded by the home’s procedures. The health, safety and welfare of residents and staff was promoted and protected. EVIDENCE: The manager had many years of experience running a care home for older people and she was undertaking the Registered Manager’s Award. The manager was only allocated twenty hours for managing the home and her other hours were worked as care hours. The provider said, he would review the manager’s allocated management hours. A deputy manager and senior care Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 20 staff supported the manager. Responsibility of key areas for safe working practice was given to each senior person and the manager monitored their work. The manager carried out regular checks of the service, records of the checks were available at the home. Staff said, the manager gave support when it is needed. The home carried out annual quality assurance surveys where residents and/or their relatives completed a questionnaire. There were not many surveys returned in the last survey therefore the home was considering further ways of getting more responses. The results of the survey were compiled in a report. Staff and residents confirmed there was regular discussion about how the home was run and they were included with any improvements and developments that took place. Financial records, of monies held on behalf of residents, were examined and found to be correct. A sample of health and safety records were examined and found to be in order. Staff had completed health and safety training and the home provided protective clothing for staff’s use. Electrical equipment checks were up to date and there was documentation for the Control Of Substances Hazardous to Health. It was confirmed that the home met the requirements of the Environmental Health Department. Training records informed care staff had completed training for: food hygiene, fire, manual handling and first aid. Staff had not completed training for infection control but some of the subject had been covered in the training for food hygiene and first aid. The home kept records of all accidents and the manager made sure measures were taken reduce the risk of Legionella. The home regularly checked the hot water outlet temperatures, in resident’s accommodation, which was controlled by thermostatic valves. Kenilworth Care Home DS0000059126.V346825.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Kenilworth Care Home DS0000059126.V346825.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. 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. Refer to Standard OP12 Good Practice Recommendations The home should keep a record of activities that take place, to show that resident’s recreational interests are being met. The Complaints Procedure should include details of: • When a complainant will receive a written response • Details of how to contact the local authority. The peeling paintwork of the laundry floor and walls should be redecorated, so they can be easily cleaned. At least 50 care staff should successfully attain National Vocational Qualification Level 2, or equivalent. 2. OP16 3. 4. OP26 OP28 Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 23 5. OP31 The manager should successfully complete management and care qualifications for National Vocational Qualification Level 4, or equivalent. The provider should review the number of management hours, which are allocated to the manager, for running the home. Care staff should complete training for infection control, which is in addition to the training they have already received. 6. OP38 Kenilworth Care Home DS0000059126.V346825.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Care Home DS0000059126.V346825.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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