CARE HOME ADULTS 18-65
Kenrick House 1777 Pershore Road Cotteridge Birmingham West Midlands B30 3DP Lead Inspector
Gerard Hammond Unannounced Inspection 15th March 2006 11:00 Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 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 Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 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. Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Kenrick House Address 1777 Pershore Road Cotteridge Birmingham West Midlands B30 3DP 0121 451 2511 0121 246 6833 charmaine_doherty@hotmail.co.uk 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) Mrs Charmaine Doherty Ms Rosemarie Brown Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. 6. Residents must be aged under 65 years Three residents with a learning disability. The home can continue to accommodate two named service user over the age of 65 with a learning disability. That the home applies for a variation on behalf of future service users who each the age of 65 years. The details regarding how the specific care and social needs of the named person must be included in the service users plan. That the named service users over 65 years` care plan, is kept under review to ensure that their needs can still be met. 24th October 2005 Date of last inspection Brief Description of the Service: Kenrick House is registered to provide accommodation, care and support for up to three people with learning disabilities. The house is a domestic scale, twostorey terraced property situated on a main arterial route into Birmingham at Cotteridge. On the ground floor there is a lounge, separate dining room, kitchen, office / staff sleep-in room, and toilet. Upstairs are three single bedrooms, a bathroom with over bath shower facility and toilet, and a separate shower room used by staff. The front door gives access directly onto the pavement outside the house, and there is restricted parking on the road outside. There is additional parking in nearby side roads. To the rear of the property is a small, enclosed garden. There is a wide range of local amenities within walking distance of the house, at either Cotteridge or Stirchley, and the area is well served by public transport. Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection visit of the current year, and was unannounced. This report should be read in conjunction with the one written following the inspection carried out on 24 October 2005. Direct observation and sampling of records (including personal files, care plans, previous inspection reports and safety records) were used for the purposes of compiling this report. Unfortunately, both residents were out of the home during the course of this inspection visit. The Manager was formally interviewed, and a tour of the premises completed. What the service does well: What has improved since the last inspection?
This has not been an easy time for staff and residents at Kenrick House, since the last inspection. One resident was terminally ill and has since passed away, so people have had to deal with a lot in the intervening period. Previous requirements relating to accurate completion of the medication administration record (MAR) and secure storage of medicines have now been dealt with. Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 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.
Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 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 Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4, 5 Residents’ needs have been assessed. Prospective residents have opportunities to visit and to try out what the service has to offer, prior to making any decision about placement. Residents have individual contracts, but arrangements for signing needs to be reviewed. Contracts should comply with National Minimum Standard 5.2. EVIDENCE: At the time of the last inspection, one of the two residents was receiving treatment for a terminal illness: sadly, this person has passed away since then. There has been one new admission. Conversations with the Manager indicated that an appropriate process has been followed. The new resident had a number of introductory visits, including overnight stays, before moving in. An assessment of her needs was provided by the social worker that arranged the placement. It was noted that the assessment contained limited information. As previously reported, residents’ statements of need should be kept under review, so as to inform future care planning appropriately. A requirement was made at the last inspection that residents’ contracts should be signed by all parties concerned. It was noted that contracts had been signed by people other than the resident in question. Where contracts are signed on another’s behalf, this should be clearly indicated, and the identity
Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 Page 9 and relationship of the person signing should be explicit. Contracts should contain all the details indicated by National Minimum Standard 5.2, including a statement of fees charged, what they cover, when they must be paid and by whom, and the costs of facilities and services not covered by fees (where this applies). Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 Page 10 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, 9 Care plans and risk assessments continue to be in need of significant development. EVIDENCE: It was noted at the time of the last inspection that care plans were in need of significant development, and this continues to be the case. There was evidence on file that some work has gone on towards expanding some of the detail contained in plans, but handwritten notes written by the Manager were not well presented or readily accessible. It is important that individuals’ plans are user-friendly working documents, and include sufficiently detailed guidance to inform the reader about exactly how support should be given. As previously recommended, appropriate use of indexing and crossreferencing could help to support this process by making information easier to find. Plans should also include residents’ agreed goals, and these should have outcomes that can be measured. Goals should be evaluated when plans are reviewed, and updated or amended as required. Whole care plans should be reviewed at least every six months with written records kept, showing who takes part and how decisions have been made.
Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 Page 11 It was noted at the time of the last inspection that risk assessments are confused with care plans, and this also continues to be the case. It is not clear whether or not there is an appropriate understanding of the process, and this may indicate a need for further training. The purpose of risk assessment is firstly to identify potential hazards and then to make judgements about the likelihood of occurrence. From this position it should then be possible to design control measures, which should minimise the possibility of exposure to the hazard occurring. These control measures should then be included in, or used to inform the individual’s care plan. Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 Page 12 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): 12, 13, 15, 17 Residents are able to take part in appropriate activities and to access the local community, but recording is still in need of improvement. People living in the house are able to keep in touch with families and loved ones. Residents have access to a healthy diet. EVIDENCE: Both of the current residents have structured day programmes at local centres. Conversations with the Manager indicate that they continue to access community facilities, but as previously reported, activity recording is poor. The Manager was unable to say what residents are doing at their respective day centres. Activities, structured or informal, form an integral part of each person’s care management. These should be directly linked to individual statements of need and to agreed goals. It is important that records are maintained appropriately, so as to inform future care planning. Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 Page 13 Both residents are actively supported to maintain contact with their families and loved ones. One resident makes weekend visits to her family on a regular basis. The other spends each Saturday visiting her mother, who is now elderly and in residential care. Stocks of food were examined and seen to be plentiful and included fresh produce. Packages of food stored in the fridge were labelled with the date of opening. The Manager advised that the menu was drawn up on a weekly basis with the residents, but that the small size of the home means that it is simple to provide alternative choices if required. Sampled menus indicated that residents have access to a diet that is balanced and nutritious. Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 Page 14 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): EVIDENCE: Standards 18, 19, 20 and 21 were all assessed at the time of the last inspection. The medication administration record (MAR) was examined, and had been completed appropriately. The medication store was secure, as required. Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Key Standards 22 and 23 were assessed at the last inspection. Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Kenrick House provides residents with an environment that is safe, comfortable and homely. The home is kept clean and tidy, and a good standard of hygiene maintained. EVIDENCE: A tour of the building was completed. As previously observed, the house is comfortable and fixtures, fittings and furnishing are of an appropriate standard. Residents’ rooms are individual, and their personal possessions and effects in evidence. The house is kept clean and tidy, and a good standard of hygiene is maintained throughout. Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 A training and development plan is still required, so that staff competence, qualifications and training needs can be assessed fully. Residents are protected by recruitment practice. Arrangements for formal supervision of staff remain in need of improvement. EVIDENCE: A previous requirement to provide a current staff training and development plan remains outstanding. The plan must show, for each person working in the home, details of all training completed and qualifications gained to date. The plan should highlight any gaps (including refreshers) and indicate when outstanding training is scheduled, and who is to deliver it. It was noted that training arranged for staff in supporting people with learning disabilities who are elderly had been cancelled by the training agency scheduled to provide it. Opportunities to provide training in Adult Protection are being explored. The small staff team currently comprises the two Registered Providers and one other member of staff. One of the Registered Providers is qualified to NVQ level 3, and the other is a Registered Nurse (Learning Disability). The other member of staff has no formal qualifications. She has been working at this home for 6 years, and the Manager reported that she has 25 years experience
Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 Page 18 of working with people with learning disabilities. Her staff record showed that references, POVA and CRB clearance had been obtained as required. The Manager advised that a new system for staff supervision and appraisal is to be introduced. However, it was noted that arrangements for formal supervision are not currently up to the required standard (six times in any twelve-month period, pro-rata for part-time staff, with written records kept of all meetings) and this should be addressed. Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42 The Manager is working towards gaining appropriate qualifications, but an improvement in record keeping, administration and organisation is required. Some thought needs to be given about how to seek the views of people using the service in a structured way. A number of issues relating to health and safety matters in the home are in need of attention. EVIDENCE: The Manager advised that she is working towards NVQ level 4, and hopes to complete this later in the year. There are currently no formal arrangements in place for quality assurance monitoring in the home, in accordance with National Minimum Standard The Registered Providers must ensure that people using the service appropriately consulted, and attention is drawn to the outcome for and 39. are this Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 Page 20 standard, which is “that service users are confident their views underpin all self-monitoring, review and development by the home”. There is an outstanding requirement that written policies and procedures comply with current legislation and recognised professional standards and cover the topics set out in Appendix 2 of the National Minimum Standards (Younger Adults). The Inspector was unable to audit this requirement, as the homes policies and procedures were not presented in such a way as to make this possible. Documents were collated in a folder, but were not organised or indexed in any way. General practice in relation to the maintenance and storage of documents in the home’s office would benefit from a thorough reorganisation, so that information can be accessed readily and easily. Sample checks of safety records were conducted. A record was available for the weekly checks of the fire alarm. Records of fire drills should show the names of all those taking part. The last available Landlord’s Gas Safety Certificate was dated 2003. No certificate in respect of the electrical hard wiring for the house was available. The last available certificate of portable appliance testing of electrical equipment was dated 2004. These matters further illustrate the need for an improvement in the general organisation and running of the home. Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 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 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 2 X 1 2 2 2 3 Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5(b-c) Requirement Contracts should be signed by all parties concerned. All signatories should be clearly identified, and the capacity in which they are signing made explicit. Contracts should comply with National Minimum Standard 5.2. Care plans should be developed as indicated in the main body of this report, to include sufficient detail so as to guide staff exactly in how support should be given. Plans should also reflect residents’ personal goals and preferences, and indicate how they have been involved in decision- making. (Outstanding since 19/03/05) Risk assessments should be developed so that potential hazards are identified correctly; the level of risk identified clearly, the likelihood of occurrence and control measures included. Risk assessments must be reviewed regularly. (Outstanding since 19/03/05)
DS0000017063.V286987.R01.S.doc Timescale for action 31/05/06 2. YA6 15(1-2) 31/05/06 12(3) 12(4a) 3. YA9 13 (4c) 31/05/06 Kenrick House Version 5.1 Page 23 4. YA12YA13 16 (2m-n) 5. YA32YA35 18(1c) 6. YA36 18(2) 7. YA37YA41 8 9 17 8. YA39 24 9. YA40 12(1) 10. YA42 13 (4c) Expand detail of activity recording. Activities should be clearly linked to individuals’ assessed needs, care plans, and agreed goals. A staff training and development plan, as indicated in the main body of this report, should be forwarded to CSCI. (Outstanding since 31/12/05) Each member of staff must be formally supervised at least six times in any twelve-month period (pro-rata for part-time staff) and a written record of each meeting maintained. (Outstanding since 31/12/05) Ensure that records required by regulation (care Homes Regulations 2001) are maintained in good order, and are accessible and available for inspection at all times. Establish and maintain a system for reviewing and improving the quality of care provided at the home, demonstrating clearly how the views of the residents have been taken into account. Written policies and procedures must comply with current legislation and recognised professional standards, and cover the topics set out in Appendix 2 of the National Minimum Standards (Younger Adults). (Outstanding since 19/03/05) Forward to CSCI current (1) Landlord’s Gas Safety Certificate. (2) 5 year electrical hard wiring certificate. (3) Certificate of portable appliance testing of electrical equipment.
DS0000017063.V286987.R01.S.doc 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 31/05/06 30/04/06 Kenrick House Version 5.1 Page 24 11. YA42 13 (4c) Ensure that records of fire evacuation drills show the names of all those taking part. 31/05/06 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 YA6YA9 Good Practice Recommendations Numbering and indexing care plans and risk assessments will make it easier to locate information and to crossreference. Personal records should include information about structured day programmes (e.g. day centre activities), and these should be linked directly to care plan goals. This will help planning to reflect a whole life approach. Consider how person-centred approaches can be introduced, in keeping with the aspirations of Valuing People. Essential Lifestyle Planning might prove a useful tool in developing support plans with residents. It is recommended that the adult protection policy is directly cross-referenced to local multi-agency guidelines, and that a copy of the guidelines is filed with the policy as an appendix. Mark the counterfoil stubs in the Accident Book with the date of the report, and the initials of the person concerned, to enable reports to be tracked if required. Put a prominent note on the Book to remind staff of the need to make reports to CSCI as required by Regulation 37 (Care Homes Regulations 2001). 2. YA12YA13 3. YA18 4. YA23 5. YA42 Kenrick House DS0000017063.V286987.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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