Inspection on 27/05/07 for Kenrick House

This inspection was carried out on 27th May 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kenrick House 22/11/07

Kenrick House 04/07/06

Kenrick House 15/03/06

Kenrick House 24/10/05

Kenrick House 23/03/05

Kenrick House 11/11/04

Kenrick House 25/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Kenrick House 1777 Pershore Road Cotteridge Birmingham West Midlands B30 3DP Lead Inspector Key Unannounced Inspection 27th May 2007 09:30 Kenrick House DS0000017063.V341355.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 Kenrick House DS0000017063.V341355.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. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 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 N/A Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 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. 4th July 2006 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. Fees are decided on an individual basis according to the service users needs but during 2007/8 are £622.07 and £546.00 per week. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We looked at all of the information that we have received about this home since it was last inspected. The Inspector called at the home without notice on a bank holiday Sunday morning, spoke with the manager and met one of the two residents. We looked around the home and looked at records. The care of residents was followed in this way to see if the home is providing a service that it should be to meet the needs of the residents. The resident that we met appeared generally well and well looked after and comfortable with staff. What the service does well: What has improved since the last inspection? The home has made improvements in some areas of its service since the last inspection. The manager is completing her qualifications and she has put right some of the things that we found to be below standard at the last inspection particularly around staff training and supervision. Important records are also better organised. Kenrick House DS0000017063.V341355.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. Kenrick House DS0000017063.V341355.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 Kenrick House DS0000017063.V341355.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): 1, 2, 3 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although not able to show how decisions about its suitability for prospective service users are made, the home has not filled its vacancy with someone who’s needs it cannot meet. EVIDENCE: The home has made no new admission. There are currently still two residents both over 70 years of age. The manager told us that they did begin the process of admitting another service user recently but decided that they could not meet her needs. There is no paper work available to support this. There are no needs assessment form or risk assessments available to support this proposed admission or to provide a framework for considering others and there should be. The decision to not admit someone who’s needs it cannot meet was a responsible one. The manager and other owner are aware of the need to match the age of any new resident close to that of the current two. The manager tells us that they are also thinking about offering a short stay provision. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 9 The home should now consider redirecting its focus to meet the needs of these ‘older adults’. This may require a change of registration conditions. The statement of purpose should be redrafted to show how the home intends to achieve this. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 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. 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. The home recognises that residents’ needs and conditions are changing and risk assessments are in place but care plans are not reviewed. The drive to ensure that individuals take an active role in planning the care and support they now need is drifting. EVIDENCE: We looked at the care files of both current residents and we spoke to one. The other was staying with relatives for the bank holiday weekend. We saw in each a lengthy document that appears to combine needs assessment with service user plan. These care plans have no date and look old. There is very little evidence of any review of either assessment or plan although the manager told us that the home is in touch with a reviewing officer at the local social services department. This is positive but there is no paperwork to support this process either. Both current residents are over the age of seventy and have mental ill health. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 11 We looked at daily notes for each resident and they show how day to day decisions are made by them but there is no evidence of how they have been involved in planning their care and support. We raised this at the previous two inspections and there has been little improvement. We saw a range of written risk assessments in each file all dated in March 2006. Without evidence of review of either of their plans of care it is difficult to judge their currency. The manager told us that she and the other owner have attended a course on care planning. The service user plans for each of these residents must be reviewed in response to a multi disciplinary assessment of their needs that includes the individual to the extent that they are able and willing to participate, so that the home can plan to meet their changing need. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home helps residents to enjoy a reasonable range of activity and leisure and family relationships are supported. Residents have a lifestyle suited to their age. EVIDENCE: We saw a list of interests and activities in one of the care files that we looked at. We spoke to the other resident about pastimes and interests and what she told us about recent outings and family contact confirmed what we had read in her daily notes. A ‘phone call came in from her family member while we were there and the ‘phone was taken to her so she could have a conversation in private. The staff member on duty was taking her out to a local pub for Sunday lunch as we left although she told us that she had no plans for how she was to spend Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 13 the rest of the bank holiday. She told us that her day centre is closed for the week. We saw her making herself tea in the kitchen and staff assisting her to put some washing through the machine and she seems comfortable enough to use the home as her own. When we arrived her breakfast was cooking in a fry pan while staff were helping her to get ready upstairs. The food sat in the fat/oil for some time before it was put between cold toast and then given to her at the table with a mug of tea. The bacon and tomato looked overcooked and greasy and not very appetizing or healthy. She was not given cutlery or a napkin and used clothes drying on an airer next to the table to wipe the grease from her fingers. She was planning to have a roast dinner two hours later. The home should take advice on healthy eating plans and talk to the residents about diet and health, make proper provision for residents while they are eating and make sure that mealtimes are reasonably spaced out. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Personal and health care is detailed in individual care files. Residents get good healthcare and receive personal support in the way that they prefer and require. EVIDENCE: We saw records in both resident’s files showing appointments for regular G.P and nurse visits, general hospital appointments, regular chiropody, dental and optician’s appointments. There are also weight records, details of medication prescribed and administered and up to date food and drink diary sheets. We saw an ‘eating’ assessment and ‘health’ risk assessment in one file as well as risk assessments for ‘sleeping’, continence, dressing and ‘sight’. Both files have medication risk assessments. The resident that we spoke to confirmed that she prefers staff to hold and manage her medication. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 15 Daily records for one resident show that her continence care is supported by staff with dignity and respect and the manager reflects this in the way that she speaks about it. All daily notes that we read for both residents show affection and care. The manager has a detailed knowledge of the health and personal care needs and presenting condition of each resident and says that specialist further mental health care intervention is necessary for one of them. We saw a referral letter to a psychology service and have already commented on the need for the home to step up progress toward a multi disciplinary need assessment and care plan review for each resident. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 16 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 good This judgement has been made using available evidence including a visit to this service. The home has a complaint procedure and staff have undertaken training in adult protection. Good policies, procedures and an ethos in the home of valuing people protect residents. EVIDENCE: We have received no complaints about the home or adult protection referrals. The home has received no complaints or made any adult protection referrals since the last inspection. We saw a pictorial complaint form in the file of each resident and saw that daily records are made about the care and well being of each resident. The owner tells us that all staff undertook some additional training in local adult protection procedures in April this year. We asked the resident who was at home when we visited if she liked living there and she said ‘yes, its very nice’. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 17 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, 25, 27, 28, 29, 30 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The home is in poor structural and decorative condition, is not kept sufficiently clean and fresh and is not likely to remain suitable much longer for the needs of the residents. Residents do not live in a comfortable home that offers them a life style suited to their age and abilities. EVIDENCE: We looked around the house with the resident who was at home when we visited and she showed us her bedroom and the empty bedroom. There is a lot of space in the house and the rooms are big and each resident has her own room. It was warm on a cool, wet and miserable May day. We found a number of problems with the fabric, interior and hygiene of the home. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 18 It is short of natural light in passage ways and landings and the light in the kitchen is being diminished by overgrown shrubs and a large tree from next door that has grown out of control. Both residents are over seventy years and eyesight tends to diminish considerably by that age. This could increase the risk of trips and falls. The kitchen is in generally poor condition and needs updating and improved ventilation. There are damp patches on the wall above the window and the plaster is breaking up. This could be condensation damage or rain fall damage. There is no radiator in the kitchen. We saw slug and snail trails over the carpet in the breakfast/dining room. The front first floor bedroom occupied by a resident has a large brown water stain on the ceiling above her bed and the wall paper is leaving the wall showing wet and crumbling plaster about a metre from the floor in the alcove opposite the door. The source of this water penetration must be found, prevented and the plaster and décor made good. Most of the external window frames at the front and the back of the house are flaking paint and showing bare wood. If left like this they will rot and become dangerous. It was raining when we visited and we saw a gutter is leaking in the back courtyard running water down the kitchen wall and creating a large puddle on the concrete courtyard. There are no bedrooms on the ground floor and no stair lift. The resident that showed us around asked us to carry her magazines down to free both her hands to manage the stairs safely. Mobility of residents is likely to deteriorate and the home should consult an Occupational Therapist about the safety of the interior environment so they can continue to move around confidently. There is one bathroom in the house with a shower over and this is sufficient for the needs of two residents but the bedrooms that we saw are large and could accommodate a shower room and toilet en-suite. There is a shower room on the landing that staff use. The shower tray is mounted on a step and the length of the shower ‘cubicle’ down to knee height is one of the front windows of the house with a plastic curtain across it. The glass is not marked as safety reinforced glass. If someone slipped in the shower they could fall through it onto the pavement below. We have told the owners to make this shower safe immediately. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 19 The garden has some good shrubs in flower and a small lawn but all are overgrown and make it difficult to access and uninviting. There is a garden bench for residents to sit on. The manager said that the gardener was due to come on the day before our visit to cut the grass again but rain prevented gardening. The shrubs should have been pruned last autumn or at least in spring so that residents can enjoy their garden. There is no blind or curtain on the window in the downstairs toilet, the light switch does not work and the fitting has no shade. This could prevent residents managing their own continence. The hot water tap does not work. Residents and staff cannot properly wash their hands. There is a light bulb missing from the central light fitting in the dining room and the ceramic soap dish fitting in the bathroom is smashed and dangerous. Minor, routine repair and replacement is not being done. The décor and layout of the house is generally dated and the furniture is dark, heavy and worn. When we told the manager that the home needed some new saucepans she said ‘we need new everything’. We asked the manager for the maintenance and renewal programme for the home but there is only a vague plan to have the windows replaced in wood secondary glazed units. The house is superficially clean only. Edges of carpets around the house are dusty showing that the vacuum cleaner is used on the centres of floors only. There are thick greasy cobwebs hanging from the smoke detector in the kitchen and the light switches are grimy. The oven is filthy with accumulated grease and the grill pan is covered with encrusted food including layers of cheese. The saucepans and cook ware in the cupboards have food deposits stuck to them and the have lost their non stick coating. The freezer drawers are stuck with ice and inside the food cupboards is dirty. We looked at two open spices containers in the cupboard and found that they are over 2 years past their use by date. The condition of the kitchen does not promote good health. Even minor urgent repairs are not being carried out and old and badly worn equipment is not being replaced. This devalues the residents. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 20 We commented in section one above under ‘choice of home’ that the home appears to be having difficulty filling its vacancy. The house although warm and spacious is not attracting or inviting or well kept. We make comments below under conduct and management of the service about planning, developing and modernising the service. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 21 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): 31, 32, 33, 34, 35, 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are properly recruited, trained and are supervised. A professional and well-motivated team looks after residents. EVIDENCE: The home is staffed and managed by the two owners and there are two other members of staff. The manager told us that no one has been recruited since the last inspection. There is no cleaner or cook, care staff carry out these tasks. Residents currently get at least one to two attention from staff. The resident that was at home when we visited had the complete attention of one member of staff all weekend. Referred to above the home is not kept sufficiently clean. The manager told us that all staff have been involved in working towards their professional training awards recently and don’t have time for much cleaning as well as looking after residents. Residents are well cared for but the home should consider employing a part time cleaner if care staff cannot keep the house clean and hygienic. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 22 We saw some notes of a staff meeting held in May this year and the owner tells us that staff have regular one to one supervision meetings and have an annual appraisal. This is positive progress. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 23 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, 41, 42, 43 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The registered person is not sufficiently in control of the direction of the business, management is reactive and there is no planning or development to bring the service up to standard. Service users are experiencing a service that is that is deteriorating EVIDENCE: One of the owners manages the home and both carry out care of residents. The manager reports that she is working on the final Unit of competence towards her Registered Managers Award. This is positive. We have been sent notification of any adverse incidents concerning residents as we should and some of the requirements made at the last inspection have been acted on. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 24 All current residents are women and women staff the home. The records that we saw are kept in good order. There is no evidence of any quality assurance systems in place for the processes of the home or to regularly gather residents and stakeholders views about the service. We raised this at the last inspection a year ago. Weaknesses in the service should not be left for us to point out when we visit, it is the registered persons responsibility to continually improve the service. We sampled records of weekly fire alarm tests for April and May this year and they are in good order. However, the domestic fire extinguisher in the kitchen looks old and rusted and should be checked or replaced. We saw the manager leave frying food unattended in the kitchen to go upstairs to help the resident get ready. This could have caught fire in her absence. The kitchen back door does not open although the lounge provides an exit in emergency. The business insurance certificate does not appear to include cover for interruption of the business costs or employers liability. This means that an extreme event could leave the home financially compromised and residents without security. The Provider must show us that this cover is in place. Referred to above the fabric of the home is deteriorating, the kitchen is dirty and cooking equipment past its safe and useful life. The garden is not attended to in good time to keep it accessible. There is no pro active planning for refurbishment, updating, replacement and renewal. This three bedded home has been carrying a vacancy for over a year. Although we acknowledge responsible management in not accepting a new resident whose needs cannot be fully met, it could be that the home is not attractive to individuals as any other than a ‘placement of last resort’ in its current state. We have doubts about its continuing financial viability. The owner tells us that the business has sufficient resources available to invest in the fabric of the house and she has been waiting for her husband who is a builder to get time to do the work. There is no evidence of any project plan. It is the responsibility of the registered person not their spouse to make arrangements to keep the home in good condition. The owners do know the residents well and have daily contact with them and with the home but management is reactive in style instead of proactive and the service is drifting and deteriorating. This could lead to a poor quality of life for the residents. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 25 We need reassurance that this home is a viable business and have asked to see a business plan and a plan for repair, renewal and refurbishment with timescales. We also need to know how major works are to be safely project managed with the minimum disruption to the residents’ lives and well being. We will require the owners to attend a meeting at our offices to tell us how they intend to improve the home. We told the manager/owner to improve and /or make safe a number of things urgently. We have not received an adequate response as we required telling us how they have done most of this. Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 26 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 2 2 2 3 3 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 3 ENVIRONMENT Standard No Score 24 1 25 3 26 x 27 2 28 3 29 2 30 2 STAFFING Standard No Score 31 2 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 3 1 x 3 1 1 Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15 Requirement Where mental health needs change for the individual this must be reflected in their written plan of care so their care is provided safely. Outstanding since 19/03/05 requirement made again compliance date 04/10/06 not met Action must be taken to identify damage to the fabric of the building that is causing moisture and snails to penetrate and repair must be carried out so that residents can live in a safe and comfortable home. The window in the shower room must be assessed for the risk its presents to residents and staff and action must be taken to minimise any identified risk. Immediate requirement The broken ceramic soap dish in the bathroom must be assessed for the risk it DS0000017063.V341355.R01.S.doc Timescale for action 01/08/07 2. YA24 23 31/07/07 3. YA27 13 02/06/07 4. YA27 13 02/06/07 Kenrick House Version 5.2 Page 28 5. YA29 23 6. YA30 13 7. YA42 23 8. YA43 25 presents to residents and action must be taken to minimise any identified risk. Immediate requirement The interior space and layout of the house must be assessed for the risks it presents to residents who have deteriorating mobility and action must be taken to minimise any identified risk Food prepared for residents must be prepared in a clean and hygienic kitchen to make sure that residents’ health is not put at risk. Urgent action required. When food is being fried it must be closely supervised so that residents are not put at risk from fire. Immediate requirement The owners must find out more about their insurance cover so that residents can be assured of continuity and safety of their living arrangements in the event of a calamity. Urgent Action Required 01/09/07 03/06/07 02/06/07 05/06/07 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. Refer to Standard YA1 YA1 YA17 Good Practice Recommendations Consult the CSCI central regional registration team about reviewing the categories and conditions of registration of the home to fit the people currently accommodated. Review the Statement of Purpose of the home in light of residents currently accommodated and changes under consideration. Residents should be able to benefit from advice and DS0000017063.V341355.R01.S.doc Version 5.2 Page 29 Kenrick House 4. YA18 guidance on a healthy, balanced diet and the home making provision for it. 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. Numbering and indexing care plans and risk assessments will make it easier to locate information and to crossreference. Residents should be able to enjoy a home that is kept properly clean 5. YA6 6. YA23 Kenrick House DS0000017063.V341355.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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