Inspection on 18/01/07 for Kenmore Home - Leonard Cheshire Disability

This inspection was carried out on 18th January 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

Kenmore Home - Leonard Cheshire... 10/06/09

Kenmore Home - Leonard Cheshire... 18/06/07

Kenmore Home - Leonard Cheshire... 05/01/06

Kenmore Home - Leonard Cheshire... 23/09/05

Kenmore Home - Leonard Cheshire... 17/03/05

Kenmore Home - Leonard Cheshire... 07/09/04

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

CARE HOME ADULTS 18-65 Kenmore Cheshire Home 100 Whitcliffe Road Cleckheaton West Yorkshire BD19 3DR Lead Inspector Helen Battle Key Unannounced Inspection 18 January 2007 11:00 Kenmore Cheshire Home DS0000001087.V312260.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 Kenmore Cheshire Home DS0000001087.V312260.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. Kenmore Cheshire Home DS0000001087.V312260.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kenmore Cheshire Home Address 100 Whitcliffe Road Cleckheaton West Yorkshire BD19 3DR 01274 872904 01274 851996 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) www.leonard-cheshire.org.uk Leonard Cheshire Mr John Hrynczyszyn Care Home 29 Category(ies) of Physical disability (29) registration, with number of places Kenmore Cheshire Home DS0000001087.V312260.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Day care - 5 Date of last inspection 5th January 2006 Brief Description of the Service: Kenmore offers nursing care for up to twenty nine people, aged 18 to 65 years, with physical disabilities. The home is a detached Victorian house set in its own grounds and has been extended to provide single room accommodation on the ground and first floor. The first floor is accessed by a passenger lift. It is situated in a residential area of Cleckheaton close to local amenities and easy access to the motorways. Kenmore is one of nineteen services run by Leonard Cheshire Services, a charity that provides services for people with a disability. The provider informed the Commission for Social Care Inspection on 25 October 2006 that the fees range from £546.00 to £1133.00 per week. There are additional charges for hairdressing, newspapers, and magazines. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Kenmore Cheshire Home DS0000001087.V312260.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this full inspection a visit to the home took place. The inspectors, Helen Battle and Bronwynn Bennett, visited the home unannounced from 11:00 hrs to 14:30 hrs. Whilst at the home, key documents such as care assessments, care plans, daily records and the staff records were looked at, and so were the rooms and garden. Four members of staff were spoken with, along with the clinical manager. Six service users were spoken with. The manager had been asked to complete a pre-inspection questionnaire. This was returned to the Commission prior to the visit taking place. Comment cards were sent to service users, their relatives, visiting professionals and GPs. Four service user surveys were returned; all were positive. Four relative surveys were returned. Two of these said there were not enough staff on duty, however generally the responses were positive. Three responses were received from health care professionals and one comment stated that a high standard of service was provided to clients. Two GPs responded; one said there was not always a senior member of staff around when they arrived at the home. What the service does well: What has improved since the last inspection? Storage of items has generally improved. Confirmation is given in writing prior to admission that the home can meet the needs of the service user. Kenmore Cheshire Home DS0000001087.V312260.R01.S.doc Version 5.2 Page 6 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. Kenmore Cheshire Home DS0000001087.V312260.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 Kenmore Cheshire Home DS0000001087.V312260.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have their individual needs assessed prior to admission into the care home. EVIDENCE: Community Care Assessments carried out by members of the multidisciplinary team are carried out prior to any service user moving into Kenmore Cheshire Home. Copies of these documents were seen in the four care record files examined. Evidence was seen of letters sent out to prospective service users confirming whether the home can meet their needs. Kenmore Cheshire Home DS0000001087.V312260.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): 6, 7, 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Plans of care are in place but not all reflect the current needs of the service user. Service users make decisions about their lives and take risks as part of a more independent lifestyle where possible. EVIDENCE: The care plans of four service users were examined. These generally did reflect the current needs of the service users. However, one of the care plans had not been adequately reviewed and there was conflicting information regarding the current needs of the service user. There was evidence of service users being involved in the formulation and review of their care plans. Entries in the daily records varied in detail. A small number of entries were very good and detailed what care and support had been given to individuals on a daily basis. The Kenmore Cheshire Home DS0000001087.V312260.R01.S.doc Version 5.2 Page 10 majority of entries, however, were poor and did not detail any information which indicated what care and support had been delivered. Due to the increase in dependency levels of the service users living at Kenmore Cheshire Home ,and the severe physical disabilities, it is difficult for service users to take risks as part of an independent lifestyle. Kenmore Cheshire Home DS0000001087.V312260.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): 12, 13, 14, 15, 16, 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users take part in appropriate activities and are part of the local community. Appropriate relationships are maintained. Service users’ rights and responsibilities are respected. Meals provided at the home are of a good standard. EVIDENCE: Service users take part in a variety of activities suitable for their needs. These include going out on trips to such as Batley Park and Leeds/Bradford airport. Some service users enjoy baking and making collages and other artwork. Games, quizzes, computers, library and in house training is available for service users. At the present time, there is no activities co-ordinator employed at Kenmore, however it was reported that the manager is looking to recruit to this post. Currently, care staff and volunteers are facilitating activities, Kenmore Cheshire Home DS0000001087.V312260.R01.S.doc Version 5.2 Page 12 however the lack of a dedicated co-ordinator impacts on the quality of the variety of the activities participated in by service users. The gardens are easily and freely accessed by service users. Service users were seen to treated with respect and their privacy and dignity maintained by staff during this visit. Service users are supported to maintain links and relationships with friends and family where possible. Service users spoken to stated that they are allowed to see visitors at any time and the home has evidently worked hard with service users to support them with maintaining relationships. The meals provision at the home is good. Feedback from service users was very positive. Kenmore Cheshire Home DS0000001087.V312260.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): 18, 19, 20. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users receive support in a way they prefer and require. Emotional and health needs are met. Service users are not protected by the home’s policy and procedure for dealing with medication. EVIDENCE: Service users spoken to stated that the staff are kind and provide personal assistance in a discreet manner which promotes privacy and dignity. Service users also stated that they are able to choose what times they get up and go to bed. There was evidence in the records of service users that support is also provided from specialist nurses. Kenmore Cheshire Home DS0000001087.V312260.R01.S.doc Version 5.2 Page 14 The medication of four service users was checked and all were found to contain discrepancies. There were a number of signature omissions, medication not booked in and recorded correctly, medication not tallying with the records, and medication prescribed on an “as required” basis not documented correctly. There was a large amount of medication waiting to be returned, and one amount of medication was not stored correctly. This is not acceptable. Requirements have been made in the last two inspection reports with timescales of 7.10.05 and 5.2.06 in relation to aspects of the medication management and have not been met. Failure to address this matter may lead to further action being taken. Kenmore Cheshire Home DS0000001087.V312260.R01.S.doc Version 5.2 Page 15 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): 22, 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally, service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. EVIDENCE: The service users spoken to felt that they could speak to any member of staff and that they would be listened to. There have been two formal complaints made to the home since the last inspection. These were fully investigated within given timescales and records held regarding these complaints and the action taken. The complaints procedure is not displayed in the home but is available should anyone request it. It is recommended that the procedure be displayed so service users and visitors can access this easily should they wish to do so. The majority of staff have received adult protection training, however the training records given to the inspector during this visit show that some staff may not have received this training for some time. The personal monies of four service users were checked and were found to reconcile with the records held. Lockable facilities are available in service user rooms for valuables. Kenmore Cheshire Home DS0000001087.V312260.R01.S.doc Version 5.2 Page 16 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): 24, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally, the service users live in a comfortable and safe environment. The home is generally clean and hygienic. EVIDENCE: A sample of service users’ rooms were seen to be personalised according to the personal taste of individuals. Two rooms were in need of new carpets and these were identified to the clinical manager at the time of the visit. Since the last visit, the outside of the window frames have been painted, and the main bathroom, link corridor and five service user bedrooms have been decorated. The area to the rear of the building has been cleared and work started to create a garden area. Kenmore Cheshire Home DS0000001087.V312260.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): 32, 34, 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff. Service users are protected by the home’s recruitment practices. Not all staff are receiving mandatory training within recommended timescales. EVIDENCE: It was reported that all but one of the day staff working at the home have received movement and handling training. The next planned phase of this refresher training is for the night staff and then ancillary staff. Adult protection training is underway. The home is looking into training a senior member of staff as a health and safety facilitator to update the rest of the staff team. Training records given to the Commission for Social Care Inspection on the day of this visit indicate that there are gaps in mandatory training for some staff. This must be addressed. Kenmore Cheshire Home DS0000001087.V312260.R01.S.doc Version 5.2 Page 18 NVQ training is also continuing at the home with 66 of care staff having achieved NVQ level 2. Other planned training includes challenging behaviour, dementia care and mouth care. The recruitment process at the home protects the service users living at the home. The records for four members of staff were examined and all had the required records and checks in place. Kenmore Cheshire Home DS0000001087.V312260.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): 37, 39, 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. Service users’ views underpin development at the home. The health, safety and welfare of service users are generally protected. EVIDENCE: The manager of the home has many years of experience in looking after this service user group. Kenmore Cheshire Home DS0000001087.V312260.R01.S.doc Version 5.2 Page 20 Service users’ views are listened to and underpin any development of the home’s policies and practices. Monthly management visits are carried out and the organisation carries out annual quality audits. This includes seeking the views of the service users via a survey. There were one apparent health and safety issue observed during this visit. The door to an upstairs sluice was not locked and a cleaning substance was stored in this room. A lock must be fitted to this door. Weekly tests of the emergency lighting and fire alarm systems are recorded. Training records indicate that not all staff are receiving fire safety updates twice a year. Kenmore Cheshire Home DS0000001087.V312260.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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 3 X 3 X X 2 X Kenmore Cheshire Home DS0000001087.V312260.R01.S.doc Version 5.2 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13.2 Timescale for action The registered person shall make 28/02/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Timescales of 7/10/05 and 5/2/06 not met. Care plans must include the 15/04/07 current needs of the service users and provide an accurate plan of care for staff to follow. All staff must receive mandatory 15/04/07 training, ie, moving and handling training as per HSE Guidance, ensure staff are up to date with POVA refresher training, fire safety refresher training. Requirement 2. YA6 15(1) 3. YA35 18(1)( c) (i) YA42 Kenmore Cheshire Home DS0000001087.V312260.R01.S.doc Version 5.2 Page 23 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. 4. Refer to Standard YA12 YA24 YA42 Good Practice Recommendations An activities co-ordinator should be recruited as planned. The two identified bedroom carpets should be replaced. A lock should be fitted to the sluice door. Kenmore Cheshire Home DS0000001087.V312260.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Team St Pauls House 23 Park Square (South) Leeds LS1 2ND 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. 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