Inspection on 21/12/05 for Kenilworth Care Home

This inspection was carried out on 21st December 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 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 01/08/07

Kenilworth Care Home 03/08/06

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 Derek Stow Unannounced Inspection 21st December 2005 11:30 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.V263423.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 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.V263423.R01.S.doc Version 5.0 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 01287 640203 Mr Sunny Okukpolor Humphreys Mrs Maureen Middleton Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Kenilworth Care Home DS0000059126.V263423.R01.S.doc Version 5.0 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. 20th April 2005 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 25 elderly people, both male and female. Thirteen of the bedrooms are located on the ground floor, offering en-suite facilities of w.c. 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. Kenilworth Care Home DS0000059126.V263423.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over four hours and forty minutes, with the inspector examining a number of records; speaking to three residents, one relative, the manager and a senior member of the Care staff. This inspection looked at those key standards, which were not examined at the last inspection in April 2005. Any issues identified as requiring action are to be found at the back of this report. What the service does well: What has improved since the last inspection? What they could do better: The home must address the issues identified at the back of the report as requiring action. Kenilworth Care Home DS0000059126.V263423.R01.S.doc Version 5.0 Page 6 In particular the home must continue to build on the formal systems which inform and support the quality of care delivered. 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 Care Home DS0000059126.V263423.R01.S.doc Version 5.0 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.V263423.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This section was not looked at during this inspection as the key Standards were examined at the last inspection in April 2005. EVIDENCE: Kenilworth Care Home DS0000059126.V263423.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9. Arrangements are in place so that service users who are assessed as being able to manage their own medication are asked if they wish to do this. The home has appropriate policies and procedures for dealing with medicines but the storage of some medicines needs to be more secure. EVIDENCE: The manager told the inspector that appropriate polices and procedures are in place for the ordering, the giving to residents and for the return of any unused medication. Observation of the facility for the storage of controlled drugs showed that this needs to be strengthened to include a locked box, in a locked cabinet (preferably fixed to the wall) in a locked room. There are currently no residents who wish to manage their own medication and the two residents who were spoken to confirmed this. Kenilworth Care Home DS0000059126.V263423.R01.S.doc Version 5.0 Page 10 The inspector spoke to two staff who are trained to administer medication and both gave a good practice account of the procedure for giving medication to residents. Kenilworth Care Home DS0000059126.V263423.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14. Residents are encouraged to exercise choice and control over their lives. EVIDENCE: Observation of two of the resident’s bedrooms confirmed that personal possessions and individualised rooms are encouraged. One resident who the inspector spoke to said, “I can come and go as I please and get up and go to bed when I like.” The manager told the inspector that the home does not handle financial affairs for any of the residents. Kenilworth Care Home DS0000059126.V263423.R01.S.doc Version 5.0 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This section was not looked at during this inspection as the key Standards were examined at the last inspection in April 2005 EVIDENCE: Kenilworth Care Home DS0000059126.V263423.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): This section was not looked at during this inspection as the key Standards were examined at the last inspection in April 2005 EVIDENCE: Kenilworth Care Home DS0000059126.V263423.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29. The home has appropriate recruitment policies in place. EVIDENCE: The manager said that the equal opportunities policy was in place, however, it was not available on the day of inspection as the manager said most of the homes policies were with an external consultant for review. The staff files that were checked had evidence of two references and criminal record bureau checks, however one file of a member of staff employed five weeks previously did not have a copy of a birth certificate or a photograph. Kenilworth Care Home DS0000059126.V263423.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 & 38. Kenilworth is run in the best interests of service users, however the homes quality assurance systems need to be strengthened. Procedures are in place for the safe keeping of residents’ money held at Kenilworth. At the time of inspection the health and safety policies and procedures were not on the premises but were being reviewed by an external consultant. EVIDENCE: Kenilworth has received the four stars of a quality service award from Redcar Council, however the homes own quality assurance systems must be strengthened to include resident surveys, feedback from other stakeholders and monthly regulation twenty-six visit reports from the proprietor. Kenilworth Care Home DS0000059126.V263423.R01.S.doc Version 5.0 Page 16 The manager told the inspector that the home does not handle financial affairs for any of the residents but that small amounts of cash is held on behalf of ten people. The records and cash were checked at random for two residents and found to be correct. One resident’s personal allowance is forwarded to the proprietor and is not held at the home, nor was the record of account up to date. This money must be held in the home so that it is easily accessible for the residents use and the account must be kept up to date. The gas safety certificate examined was up to date and all staff had undertaken fire training with evacuation training being planned for February 2006. The manager said that new smoke detectors had recently been installed and the records showed that the hard wiring system had been passed on 19th October 2005. Kenilworth Care Home DS0000059126.V263423.R01.S.doc Version 5.0 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 2 X X 2 Kenilworth Care Home DS0000059126.V263423.R01.S.doc Version 5.0 Page 18 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 OP37 Regulation 26 Requirement A written report must be provided by the registered provider to the manager and a copy to the CSCI detailing his monthly visits to the home. (Timescale of 20/5/05 not met) The radiators in all the en suites must be covered, or must be replaced with low surface temperature radiators where covers cannot be provided. (Timescale of 20/05/05 not met) The Health & Safety policies and procedures must be available at the home. The stained carpet squares leading from the entrance hall to the lounges/front hall must be replaced. (Timescale of 01/07/05 not met) The facility for the storage of controlled drugs must be strengthened to include a locked box, in a locked cabinet DS0000059126.V263423.R01.S.doc Timescale for action 31/12/05 2. OP38 13 31/01/06 3. OP20 23 31/01/06 4. OP9 13. 31/01/06 Kenilworth Care Home Version 5.0 Page 19 (preferably fixed to the wall) in a locked room. 6. OP12 16. 7. 8. OP29 OP18 19 13. 9. 10 11. OP36 OP35 OP33 18. 17 24. The manager must arrange for an activities programme to be developed and consult with residents regarding proposed activities. All staff files must contain a copy birth certificate and a photograph. All staff must receive Training/instruction in the newly developed adult protection procedure. Care staff must receive formal supervision at least six times a year. The home must keep a record of all monies that are held on behalf of residents. A service user satisfaction questionnaire survey must be carried out at least yearly and the results published and made available to interested parties including CSCI. 31/01/06 31/01/06 31/01/06 31/03/06 31/01/06 31/03/06 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 OP28 Good Practice Recommendations 50 of staff should have achieved NVQ level 2 in care. Kenilworth Care Home DS0000059126.V263423.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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. 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