Inspection on 04/07/06 for Kenrick House

This inspection was carried out on 4th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. 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 27/05/07

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

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Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

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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 Sara Gibson Unannounced Inspection 4th July 2006 09:00 Kenrick House DS0000017063.V293382.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.V293382.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.V293382.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 guccigirl167@hotmail.com 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.V293382.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. 15th March 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. Kenrick House DS0000017063.V293382.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection process took place during June and July 2006. Information and evidence was gathered from looking at previous inspection records and the requirements made. A visit to the home was made where the Inspector looked at the homes paperwork including care plans, risk assessments, staff personnel files and safety records. The Manager was working at the home and was very helpful during the visit. The Inspector had a look round the home and was also able to sit and have breakfast with the two ladies who live at Kenrick House. During breakfast the Inspector talked with both the ladies who although had limited communication were able to tell the Inspector that “I am happy here” “The girls are nice, good, they look after me” “Food nice, I like the food” “ I watch television today” “Going to the theatre for my birthday” “I see my mum Saturday, go see her” “I got nice room, I like my bed”. From these comments the ladies at Kenrick House seemed happy and enjoyed living there. What the service does well: What has improved since the last inspection? Care plans and risk assessments have been further developed and give an holistic picture of the service users, although review dates must be noted. Activity recording is much improved, and there is good communication between the home and the day centres attended by the service users. Requirements made from the last inspection pertaining to health and safety matters have been actioned. Kenrick House DS0000017063.V293382.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.V293382.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.V293382.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 and 5 The quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. Service users needs are fully assessed, and prospective service users have opportunities to visit and try out what the service has to offer, prior to accepting a placement at Kenrick House. EVIDENCE: There are currently two service users at Kenrick House. There have been no new admissions since the last inspection. Each service user had a full assessment prior to accepting a place at Kenrick House and has an individual contract with the home which has been appropriately signed and witnessed. Kenrick House DS0000017063.V293382.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to the service. Care plans and risk assessments are much improved since the last inspection, although some archiving of old documentation would make the service users care files more presentable, and current information more accessible. EVIDENCE: Care plans examined contained a lot of information about each service user. It was obvious from reading through the care plans that the staff know the service users very well. Entries show that staff are aware of the triggers that may result in behavioural changes in the service user, and how to deal with these changes. Care plans contain detailed information on service users needs, how they are to be met and the expected outcomes, though care plans were not dated and there was no evidence of when the care plans were last reviewed. Care plans must be reviewed at least every 6 months, with written records kept showing who took part and how decisions were reached. There is no evidence to show that service users have had input into their care plans. Kenrick House DS0000017063.V293382.R01.S.doc Version 5.1 Page 10 From observing staff interaction with service users, it was clear that service users are given the appropriate support to make choices about their daily lives whilst maintaining their independence. The risk assessments seen were good, potential hazards were identified and control measures in place to reduce the risks. Again, these need to be dated and regularly reviewed and updated. Service users files need to be more organised, indexed and cross-referenced with the risk assessments to provide a clear picture of the service user. Old documentation should be archived to allow the current information to be readily accessible Kenrick House DS0000017063.V293382.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 The quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. Service users have a varied and interesting lifestyle, activities are appropriate and well-planned according to their age and abilities. Personal relationships are actively encouraged and maintained with staff support. Service users rights are respected and their responsibilities recognised in their daily lives. A healthy, nutritious and varied diet is on offer to service users, and mealtimes are enjoyed. EVIDENCE: Both of the current service users are older ladies and have structured day programmes at local centres, where they enjoy many varied activities such as reminiscence sessions, old time music, trips to the theatre and places of local interest. The day centres and the home communicate well with each other regarding the service users. Kenrick House DS0000017063.V293382.R01.S.doc Version 5.1 Page 12 Likes, dislikes and activity preferences are documented in the care file. On speaking with the service users they stated they enjoyed watching television, knitting, helping in the kitchen, going to the day centres and trips out. One service user has a trip to the theatre arranged for her birthday. Both residents are actively supported to maintain contact with their family and friends. One service user makes fortnightly weekend visits to stay with her family. The other service user speaks to her mother daily on the telephone, and visits her every Saturday, she also has friends who take her out during the week. Service users are given choice in all their daily activities, and their independence is encouraged by recognising their daily responsibilities. Rights of service users are respected by all staff. Mealtimes are relaxed and unhurried. Breakfast time was observed during this inspection. The table was nicely laid with individual teapots and milk jugs for each service user. An array of cereals were available, and toast was offered to both service users. Encouragement was given by staff but no assistance was necessary. Records of food eaten are maintained, and service users are weighed monthly. The kitchen was clean and hygienic, food was stored appropriately, labelled and dated. Service users have a daily choice of menu, and food offered is nutritious, healthy and balanced. Kenrick House DS0000017063.V293382.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. Service users are supported with their personal needs by care staff, encouragement is given and independence is maintained. Medication is stored appropriately and administered by staff. EVIDENCE: Both service users are supported by staff with their personal needs, encouragement is given and independence is maintained. Service users physical and emotional health needs are well met by staff. From examining care plans and daily reports, and from observing interaction between service users and staff, it is clear that the staff know the service users very well and are aware of triggers that may result in a service users change in behaviour. Input from GP’s and CPN’s are documented in the care plan. Regular general health checks are carried out by the GP, monthly weights are recorded and meetings are held regularly with the CPN to discuss any issues regarding the service users mental health. Kenrick House DS0000017063.V293382.R01.S.doc Version 5.1 Page 14 Medication is stored securely, administered by staff and recorded appropriately on the medication administration record (MAR chart). Kenrick House DS0000017063.V293382.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): 22 and 23 The quality outcome in this area is good. The judgement has been made using available evidence including a visit to the service. Service users are listened to and any issues raised are actioned by staff. The home has POVA (Protection of Vulnerable Adults) policies in place, and all staff have an awareness of adult protection procedures which safeguard the service users. EVIDENCE: The home has a complaints policy which shows how complaints are recorded, actioned and followed through. Service users are able to raise issues independently and talk to staff freely. If any concerns are raised they are documented and actioned by staff in the daily reports log. There is a complaints log in the home, no complaints have been received since the last inspection. The home has POVA policies and procedures in place in line with the Birmingham Multi-Agency Guidelines. All staff have a copy of the POVA policy and an awareness of adult protection procedures. It is recommended that all staff undertake a formal course in adult protection procedures to further safeguard the service users. No complaints or concerns have been received from relatives or service users representatives. Kenrick House DS0000017063.V293382.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): 24,25,26,27,28 and 30 The quality outcome in this area is good. The judgement has been made using the available evidence including a visit to the service. Kenrick House provides service users with an environment that is safe, comfortable and homely. The home is clean and tidy, and a good standard of hygiene is maintained. EVIDENCE: A tour of the home was undertaken. The home is comfortable and spacious. The lounge is homely and comfortable, with a service users birthday cards on display on the bookcase. Fixtures, fittings and furnishings are of an appropriate standard. Service users bedrooms are individual and very personalised with the service users own possessions and effects in evidence The kitchen and bathroom were clean and tidy, and a good standard of hygiene is maintained throughout the home. Kenrick House DS0000017063.V293382.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 and 36 The quality outcome in this area is adequate. The judgement has been made using the available evidence including a visit to the service. Service users are protected by the home’s recruitment practice. Staff duty rota’s are planned in advance and show a full complement of staff employed by the home. Agency staff are not used. A staff training and development plan must be provided so that staff competence, qualifications and training needs can be fully assessed. Staff supervision records were not available for inspection. The Manager must ensure that all records pertaining to the home, service users and staff be kept on the premises at all times. EVIDENCE: Staff personnel files were examined and found to contain satisfactory references, CRB and POVA checks. Records of induction were in place, and staff have been issued with terms and conditions of employment. Records of training were incomplete, although all staff had recently undertaken training in First Aid and Care Planning. Two of the staff are near completion of their RMA (Registered Managers Award), and a third is currently working through an NVQ2 in Care. Kenrick House DS0000017063.V293382.R01.S.doc Version 5.1 Page 18 A staff training and development plan must be provided to show details of all training completed, qualifications gained to date and future training planned for each staff member including updates in mandatory subjects such as Moving & Handling, Health & Safety and Food Hygiene. It is recommended that all staff undertake training in adult protection procedures to further safeguard service users. Staff supervision records were not available for inspection. The Inspector was informed that they were with the NVQ assessor. The Manager was reminded that all records pertaining to the home, service users and staff must be kept on the premises and be available for inspection at all times. Kenrick House DS0000017063.V293382.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 and 42 The quality outcome in this area is adequate. The judgement was made using the available evidence including a visit to the service. The Manager is working towards gaining the RMA (Registered Managers Award), but an improvement in the general administration and organisation of the paperwork in the home is required. Service users views are sought by the home but need to be documented appropriately. The health, safety and welfare of the service users is promoted and protected. EVIDENCE: The Manager is near completion of the RMA (Registered Managers Award) but needs to improve the general administration and organisation of the paperwork in the home. Kenrick House DS0000017063.V293382.R01.S.doc Version 5.1 Page 20 Although all the records seen contained the relevant information, a number of the documents were not dated or well presented. A large number of the files require archiving to enable the current information to be accessed easily. Views of the service users and their relatives/representatives are sought regularly but a formal quality assurance system needs to be introduced to document these views and show any action taken as a result of the issues raised. Safety records were seen and noted to be up-to-date and current. Fire drills take place regularly and are documented appropriately. A thorough reorganisation, review, collation and archive of the paperwork in the office must take place so that current information is easily accessible and available for inspection at any time. Kenrick House DS0000017063.V293382.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 X 5 3 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 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X 2 3 X Kenrick House DS0000017063.V293382.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 YA6 Regulation Requirement Timescale for action 04/10/06 15(12)12(3)12(4a) Care plans must be developed further to reflect service users personal goals and preferences, and indicate how they have been involved in decision making. Care plans must be reviewed at least every 6 months. Outstanding since 19/03/05. 13(4a-c) Risk assessments must be reviewed regularly. Outstanding since 19/03/05 A staff training and development plan, as indicated in the main body of this report, should be forwarded to CSCI by 4th August 2006. 2. YA9 04/10/06 3. YA32YA35 18(1c) 04/08/06 4. YA36 18(2) Each member of staff 04/08/06 must be formally supervised at least six times in any twelve-month period (pro-rata for partDS0000017063.V293382.R01.S.doc Version 5.1 Page 23 Kenrick House time staff) and a written record of each meeting maintained. These records must be kept in the home at all times. 5. YA39 24 Ensure service users views 04/10/06 and those of their relatives/representatives are formally documented as part of the homes quality assurance programme. Ensure that all records 04/09/06 required by regulation are maintained in good order, and are accessible and available for inspection at all times. 6. YA41YA37 8&9 17 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 YA6 Good Practice Recommendations Numbering and indexing care plans and risk assessments will make it easier to locate information and to crossreference. Archiving old documentation will enable current information to be accessed easily. 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. All staff should receive further training in adult protection procedures to further safeguard service users. 2. YA18 3. YA23 Kenrick House DS0000017063.V293382.R01.S.doc Version 5.1 Page 24 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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