Inspection on 03/08/06 for Kenilworth Care Home

This inspection was carried out on 3rd August 2006.

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 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 Neil McKenzie Key Unannounced Inspection 09:30 3 and 8th August 2006 rd 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.V305580.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.V305580.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 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Kenilworth Care Home DS0000059126.V305580.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. 21st December 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.V305580.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. The inspection lasted for 7 hours and this included 2 visits to the home. The reason for the inspection was to see how good a job the home does in meeting the National Minimum Standards for Care Homes. During the visits the inspector spoke to 3 residents, 1 relative and 2 staff to find out what their views were about living and working at Kenilworth. The inspector also spent time speaking to the Manager and the owner of the home. The inspector spent some more time watching how staff and residents are with each other. A tour of the home took place and records looked at included staff recruitment and training, resident care plans and how the home handles medication and money. There was also questionnaire’s sent to the home, residents and relatives and these were looked at to help decide how good a job the home does in meeting the National Minimum Standards. At the time of the inspection the minimum and maximum cost for a bed was £345.00 What the service does well: Residents and relatives spoken to and survey questionnaires returned were on the whole satisfied with the level of support and care provided by the home. For example, one relative stated in the survey ‘ This is an excellent care home, residents are well loved and cared for’. A resident commented, ‘I don’t think you could organise it any better here, they are very good’. The residents also benefit from courteous staff respecting privacy. The inspector on numerous occasions observed staff knocking and seeking permission before entering a resident’s room. As a relative visiting the home stated, ‘ I call every day and you are always made to feel very welcome’. The home appeared to be clean and pleasant with a relaxed and friendly atmosphere. Kenilworth Care Home DS0000059126.V305580.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. Kenilworth Care Home DS0000059126.V305580.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.V305580.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to this home. The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents’ benefit from comprehensive assessment of needs and care plans. EVIDENCE: Care plans and care records examined contained detailed assessments of the residents’ original needs by qualified professionals and these original assessments contained evidence of updating as the residents’ needs change. The care staff who spoke to the inspector were clear about resident assessment needs and both staff and residents were able to confirm that they had access to these plans and referred to them. As one staff member stated, ‘ I am involved with care plans and daily records’. Kenilworth Care Home DS0000059126.V305580.R01.S.doc Version 5.2 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): 7,8,9 and 10 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Each resident has a plan that considers their health, personal and social care needs. The home ensures that these plans are reviewed on a regular basis and where agreed involves the family. Residents’ who are not responsible for their own medication are protected by trained and qualified staff who administer the medication. The homes policies and procedures need updating to state the new procedure for the storage, administration and disposal of controlled medication. Residents spoken to felt they were treated with respect and dignity. EVIDENCE: In the files sampled by the inspector each resident had a personal care plan that is reviewed on a regular basis and supported by daily records documented in their file. The records supporting the care plan demonstrate evidence of other specialist professionals such as District nurses involved. Kenilworth Care Home DS0000059126.V305580.R01.S.doc Version 5.2 Page 10 This care plan is promoted by the home as each resident is allocated a key worker and resident specific training is provided for the key worker. Relatives and residents were on the whole satisfied with the level of care agreed in their care plans. One relative stated in a returned survey, ‘ until my mother went to this home she was virtually wheelchair bound. The staff at this home have taken the time to get her back on her feet and with the aid of her walking frame given her back her mobility, something that a stay in hospital and a stay at another home failed to do so’. Residents interviewed referred to specific aspects of their care, for example one resident commented, ‘ I am a diabetic so I can only eat certain things, and I receive an injection every morning by one of the nurses. During the inspection the home’s arrangements for receiving, storing, administering, recording and returning resident’s medication were observed, examined and discussed in depth with the manager. At the time of the inspection visit, medication was not correctly stored and administered with regard to controlled drugs. This required immediate action by the manager and the home has now introduced safe practices recommended by the Royal Pharmaceutical Society guidelines for care homes. This includes separate storage and records for controlled drugs that are now counter signed when administered by qualified members of staff. The manager was also able to show and describe how medication is disposed of and how this is recorded. Whilst the home has now made improvements with regard to looking after resident’s medication this would be made better if the policy and procedures were updated to include the new procedures for the storage, administration and disposal of controlled drugs. Individual residents’ medication record sheets contain photographs of the person to help ensure that residents receive the correct medication. The residents’ who spoke to the inspector stated that staff treated them with respect and dignity: ‘Lovely here, staff are really good to you and nothing is a trouble’ ‘Staff friendly and homely, you are made to feel welcome’ The inspector on numerous occasions observed staff knocking and seeking permission before entering a resident’s room. Kenilworth Care Home DS0000059126.V305580.R01.S.doc Version 5.2 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): 12, 13 14 and 15 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Family members are made to feel welcome when visiting the home. Residents and family are consulted about opportunity to take part in activities inside and outside of the home but a number of residents felt there could be more done in this area. Residents are on the whole satisfied with their food. EVIDENCE: All relatives spoken to and returned survey questionnaires said they were made to feel welcome in the home at any time. As a relative visiting the home stated, ‘ I call every day and you are always made to feel very welcome’. A resident also commented,’ relatives visit every week, three times per week, and they come when they want to come’. Kenilworth Care Home DS0000059126.V305580.R01.S.doc Version 5.2 Page 12 A number of residents did comment that there could be more organised activities outside of the home; ‘Wish there were more activities to join in with at the home’ ‘Do not get out very much’ ‘Like more active life, men like to drink’. During the inspection visits this was taken up by the home as they displayed a number of arranged activities for the summer that residents could choose to take part in. Residents who spoke to the inspector said they were encouraged to make their own decisions about their daily lives. One resident stated, ‘ I don’t think you could organise it any better, they are very good and the staff help me look after my money and there are no problems there’. On the whole residents were observed to receive a wholesome and balanced diet with choice for a more personal menu and choice to eat in their own rooms. One resident said; ‘Food very, very, very, good’ Eight out of ten resident surveys returned stated the food was always good. Kenilworth Care Home DS0000059126.V305580.R01.S.doc Version 5.2 Page 13 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): 16 and 18 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are protected by a complaints procedure that is available in the home and policy and procedures on Adult protection and prevention of abuse. EVIDENCE: The home has a complaints procedure that is displayed. Nine out of the ten resident surveys returned stated they were aware of the homes complaints procedure. There have been no complaints in the past 12 months recorded in pre-inspection questionnaire completed by the manager. The residents are protected by an Adult Protection and Prevention of Abuse policy. Staff interviewed stated they had training on ‘no secrets’ and the Manager and a Senior Care worker stated they had completed recent training course on the Protection of Vulnerable Adults. Kenilworth Care Home DS0000059126.V305580.R01.S.doc Version 5.2 Page 14 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): 19 and 26 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The residents on the whole live in a well maintained home. The home presented as free from unpleasant odours. EVIDENCE: A tour of the home showed residents living in a pleasant, comfortable home that is well looked after and kept clean and tidy. There was evidence of bedrooms recently decorated and carpets replaced. During the inspection the home replaced stained carpet tiles in the main hallway. The quality of the homes environment should continue to be improved by replacing the carpet on the top floor landing and upgrading resident bedrooms. Kenilworth Care Home DS0000059126.V305580.R01.S.doc Version 5.2 Page 15 Residents have bedrooms that have lots of their personal belongings as well as plenty of communal space to spend time in. The home has two lounges for residents. Kenilworth Care Home DS0000059126.V305580.R01.S.doc Version 5.2 Page 16 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): 27,28,29 and 30 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Evidence indicates that on the whole residents’ needs are met by the number of staff on duty and by a compliment of trained staff. One staff personnel file did not contain all of the required information. EVIDENCE: An audit of the duty rota was carried out. At the time of the inspection there were 24 residents living at the home. There was 1 trained nurse and four care assistants during the morning shift. This included a chef and domestic. There was 1 trained nurse and 3 care assistants for the afternoon and evening shift and 1 trained nurse and 1 senior care assistants for the night shift. There are 16 care staff 8 currently have their National Vocational Qualification Level 2 or 3. One of the personal files did not contain a signed verification of a second reference applied for by the home. Kenilworth Care Home DS0000059126.V305580.R01.S.doc Version 5.2 Page 17 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): 31, 33, 35, 36 and 38 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is run and managed by a person who is fit to be in charge. Currently staff formal supervision happens once a year when it should be held at least 6 times a year. Residents and relatives are formally consulted about their views of the home although due to low return there are no findings published. Resident is safeguarded by a recent health and safety policy and procedures introduced to the home. EVIDENCE: The manager was clear about her role and responsibilities, and handled the inspection in a knowledgeable and professional manner. As one resident stated, ‘ I have a lot of faith in the manager with regard to any concerns’. Kenilworth Care Home DS0000059126.V305580.R01.S.doc Version 5.2 Page 18 The manager is due to start a National Vocational Qualification Level 4 in management. This has been recommended in two previous inspection reports. The owner of the home is currently completing a relevant course in management. The residents must benefit from a staff team supported by regular supervision on the work they do by the manager. Monthly reports completed by the owner of the home the home is doing but copies of these should be sent Social Care Inspection every month. The home has a plan that would be better supported by completed surveys that comment and contribute to this plan. comment on how well to the Commission for business development resident and relative Policy and procedures are available with regard to the handling of resident’s money and the 3 transactions that were sampled during the inspection were correct. Details of health and safety were made available through the pre-inspection questionnaire. With regard to health and safety the home must ensure they have an up to date Gas Safety Certificate once work is completed in installing a new gas dryer. The banisters at the old front entrance that is no longer used by residents but can access via the garden are rotten and are a potential hazard and must be made safe. Kenilworth Care Home DS0000059126.V305580.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 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 2 Kenilworth Care Home DS0000059126.V305580.R01.S.doc Version 5.2 Page 20 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 OP9 Regulation 13(2) Requirement The registered manager must ensure there is a policy and staff adhering to procedures for receipt, recording, storage, handling and disposal of all medicines. A programme of routine refurbishment and decoration of the premises must continue to be implemented. The registered manager must ensure regular servicing of gas appliances by competent person and rotten banisters at front entrance are made safe. Care staff must receive formal supervision at least six times a year (Previous timescale of 31/03/06 was not met) A service user satisfaction questionnaire survey must be carried out at least yearly. (Previous time scale of 31/03/060 was not met) Timescale for action 08/08/06 2. OP19 23(2) 08/08/06 3. OP38 12(a) 31/08/06 4. OP36 18(2) 08/08/06 5. OP33 24. 29/09/06 Kenilworth Care Home DS0000059126.V305580.R01.S.doc Version 5.2 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP31 OP12 Good Practice Recommendations The manager should obtain a qualification in management The manager should regularly consult with residents about a programme of activities. Kenilworth Care Home DS0000059126.V305580.R01.S.doc Version 5.2 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Kenilworth Care Home DS0000059126.V305580.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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