Inspection on 23/09/05 for Kenmore Home - Leonard Cheshire Disability

This inspection was carried out on 23rd September 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 no outstanding requirements from the previous inspection report, but 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... 18/01/07

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

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 Bronwynn Bennett Unannounced Inspection 23rd September 2005 09:30 Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 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.V252491.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 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.V252491.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kenmore Cheshire Home Address 100 Whitcliffe Road Cleckheaton West Yorkshire BD19 3DR 01274 872904 01274 851996 kenmorec-uk.org 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) Leonard Cheshire Mr John Hrynczysyn Care Home 29 Category(ies) of Physical disability (29) registration, with number of places Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Day care - 5 Date of last inspection 17th March 2005 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. Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by two inspectors. Some of the service users, staff, and three relatives were spoken with. The written records kept by the home were looked at. What the service does well: 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. Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 6 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.V252491.R01.S.doc Version 5.0 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed during this inspection. Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. The staff are working hard to meet the individual needs of the service users. EVIDENCE: All the service users spoken with said that they were satisfied with the level of care and the support they receive from the staff at the home. There were comments such as “ The staff are very good” and “ The staff are kind”. One relative advised the inspector that the staff in the home are “marvellous”. The care records were looked at for four service users. These records were detailed, well laid out and easy for the reader to follow. The care plans identify the individual needs of the service user and were reviewed and updated. It was noted that the overall standard of the care records has improved since the last inspection. The daily recording in these files was vague and did not reflect how the service user had spent their day. Some service users have complex needs and communication difficulties and it may be a challenge for them to be involved in the evaluation of their care needs. However, there was no evidence in the care records looked at that the service user had been involved in their care plan. One service user said that Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 9 they were unaware that they had a care plan. This needs to be addressed by the staff. One service user said that the staff offer support to enable the individual make decisions. The organisation has the policy and procedure in place for the service users to make decisions and risk taking. Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,15. The service users are supported to develop and maintain family and personal relationships. The service users are part of the local community. EVIDENCE: The service users are supported to be part of the local community. One service user said that the staff support her to go out to the local church. There is advice available for the local MP’s advice surgery. There is variety of activities available for the service users and these are displayed on the service users information board. One service user said that the staff support him, to enjoy the homes garden facilities. During this inspection the service users were holding a coffee morning. The service users spoken with said that their friends and family are always welcome in the home and there are no restrictions for visiting. Two relatives said that the staff make them feel welcome. The service users can develop and maintain personal relationships. The home has a relevant policy and procedure in place for personal relationships and service users rights. The service users have access to advocacy services. Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. The staff are working hard to ensure the healthcare needs of the service users is met. The storing of medication for disposal poses a health and safety risk. EVIDENCE: During this inspection the service users were seen being supported by the staff in a dignified and respectful manner. The staff were observed talking and interacting with the service users. The personal support required by the service user was seen in the individuals care records. The home provides physiotherapy service. There is support from the Macmillan nurses and a spinal injuries unit. There are plans for some staff to attend training for spinal injury care. There care records looked at had risk assessments in place. These records were detailed, easy to follow and reviewed. The medication records were looked at for four service users. All the medication could be reconciled with the records kept, with the exception of one signature omission. The deputy manager advised the inspector that the organisation has not yet made suitable arrangements for the disposal of medication. This is not acceptable and needs to be addressed. Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. The service users feel confident to raise concerns or make a complaint. EVIDENCE: The service users spoken with said that they felt that their views are listened to and acted upon, and that they would feel comfortable in making a complaint. The acting manager advised that the service users have agreed to hold two monthly meetings. The home has a complaints policy in place and keeps a record of any complaints made. There were no details displayed in the home of how to make a complaint and this should be addressed. The organisations “ Have your say” leaflet did not give the information of how to contact the Commission for Social Care Inspection and this was discussed with the acting manager. The home has a policy for the protection of vulnerable adults and a whistle blowing policy in place. The staff spoken with had a good understanding of the appropriate action to take should there be any allegations of abuse. Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,30. The staff must adopt safe working practices to minimise the risk of cross infection. Greater care needs to be taken to ensure the home is clean and hygienic. EVIDENCE: The library area has recently been fitted with new chairs and the chairs in the smoking area have been fitted with new cushions. The service user area was free from storage and is now accessible. Some areas of the home were generally clean and tidy, however some areas such as the radiators, stairway and a toilet were in need of a thorough clean and a bathroom was in need of general maintenance. A corridor did have an odour and another corridor did not have adequate lighting for the service users and this was discussed with the acting manager. There were cleaning products left in two of the bathrooms and this poses a potential health and safety risk to the service users. Two baths were left in need of cleaning after use. This practice does not control the risk of cross infection and must be addressed. Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed during this inspection. Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39,42. EVIDENCE: The service users said that they feel that their views are listened to and acted upon. The organisation an annual quality monitoring survey and the findings and any actions in response to the survey are published. A sample of maintenance records and certificates was checked and were up to date. There are monthly health and safety checks that are carried out in the home. There was no recording of bath temperatures available for the previous month and this needs to be addressed without delay. Fire testing is conducted on a weekly basis but there was no evidence of the homes fire risk assessment and this was discussed with the acting manager. The training officer advised the inspector that the organisation is in consultation regarding the updating periods for movement and handling training. The recommendation of annual updates for movement and handling continues in order to avoid injury to the service users and the staff. Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 16 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X x Standard No 22 23 Score 1 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 1 X X 2 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X x CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kenmore Cheshire Home Score 3 3 1 x Standard No 37 38 39 40 41 42 43 Score X X 3 X X 1 x DS0000001087.V252491.R01.S.doc Version 5.0 Page 17 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. Standard YA20 Regulation 13.2 Timescale for action The registered person shall make 07/10/05 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The complaints procedure must 14/10/05 include the details of the Commission for Social Care Inspection. The registered person shall 14/10/06 ensure that cleaning materials are not left in service users bathroom and toilet facilities. The registered person shall after 14/10/05 consultation with the fire authority take adequate precautions against the risk of fire, including the provision of suitable fire equipment. Requirement YA22 22 YA27 13.4(a) YA42 23.4(a) Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 18 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 3 4 Refer to Standard YA6 YA24 YA30 YA42 Good Practice Recommendations Wherever possible the service users should be involved in the development and the review of their plan of care. The lighting in the identified corridor needs to be suitable for the service users. A suitable cleaning schedule should be in place to ensure all areas of the home are kept clean, free from odour and to control the spread of infection. The care staff should receive annual movement and handling training. The hot water temperatures should be completed on a weekly basis. Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Kenmore Cheshire Home DS0000001087.V252491.R01.S.doc Version 5.0 Page 20 - 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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