Inspection on 26/04/05 for Kensington

This inspection was carried out on 26th April 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kensington 12/07/07

Kensington 12/07/06

Kensington 19/07/05

Kensington 05/11/04

Kensington 05/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Kensington Ayton Street Byker Newcastle upon Tyne NE6 2DB Lead Inspector Aileen Beatty Unannounced 26 April 2005 09:30 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 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 Older People. 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. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Kensington Address Ayton Street Byker Newcastle upon Tyne NE6 2DB 0191 265 2888 0191 276 2888 N/A Mr Baldev Singh Ladhar Telephone number Fax number Email 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 Lillian Lancaster CRH 49 Category(ies) of OP Old age (47) registration, with number PD Physical disability (2) of places Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: The five bedrooms registered in the basement of the home are to be occupied by service users who require personal care only. Date of last inspection 5th November 2004 Brief Description of the Service: Kensington is a home providing nursing and residential care. It is situated in a residential area of Byker, on the outskirts of Newcastle upon Tyne. The home is purpose built and was first registered in August 2000. Accomodation is provided over three floors. The lower ground floor has five beds registered for personal care only. A passenger lift is available, if required. The bedrooms are all ensuite and of a good size. Double bedrooms are available if required. There are lounges available on each floor and a designated smoking area. There are two homes on this site and they share kitchen and laundry facilities. They are otherwise independently staffed and function separately. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 09.30 a.m. It took place over 5 hours and included a tour of the premises, inspection of records and discussion with staff and service users. Residents were joined for lunch. What the service does well: What has improved since the last inspection? A number of requirements from the last inspection have not been fully met. However progress is being made towards meeting these. Care plans are being checked regularly by the manager and are more up do date. Staff are keeping written records of personal care tasks they carry out, and diet and fluid charts were up to date. An activities co-ordinator has been employed and some new resources bought. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, and 4. Standard 6 is not applicable as intermediate care is not provided. The needs of service users are assessed and assurances given that these can be met prior to service users being admitted to the home. Staff are suitably experienced to meet the needs of residents but further formal training needs to be provided. EVIDENCE: Care records were examined for 4 service users. All contained comprehensive assessment information that had been received by the home before the admission of these residents. Care plans were available and were based on the information from the care manager assessment and their own needs assessment. A requirement set at the last inspection relating to the full completion of pre admission documentation has been met. Qualified nursing staff are available in the home 24 hours a day. There is evidence of relevant ongoing training for all staff. Specialist support is provided Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 9 by district nursing services and tissue viability specialists if necessary. A District Nurse who has regular contact with the home, was very complimentary about the standard of care provided. 6 residents said that they feel well looked after, and when asked, could not think of anything they would like to change. Two staff have NVQ level 2 training and all other staff are currently completing this. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10. The overall standard of care provided is good. There have been improvements in the standard of record keeping in relation to direct care. Further improvement is necessary. Service users are treated with respect but some monitoring of this is necessary to ensure the dignity of service users is not unintentionally compromised. Procedures for the administration of medicines are not followed satisfactorily although some improvement was noted. EVIDENCE: The standard of record keeping has improved. All residents have individual care plans and completed assessment information relating to diet, mobility, pressure areas, falls risk, and social needs. These assessments are not always kept up to date. Care plans are not always reviewed monthly but have been reviewed more often than previously. Where residents are found to be at risk of developing pressure sores, preventative care plans must be provided. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 11 Accountability sheets have been introduced to ensure that staff check that all aspects of personal are carried out effectively. Residents appeared clean and well cared for during the inspection. Food fluid and hygiene charts that were found to be out of date at the last inspection were up to date at this one. 3 residents had pressure sores at the time of the inspection. Care plans were in place for these people. Unexplained gaps were noticed in medication administration records (MAR sheets). Handwritten entries on MAR sheets are not always countersigned. At the last inspection, it was identified that dates of opening were not written on eye drops. Dates were written on these preparations at this inspection. “Ensure” food supplement drinks found in the dining room cupboard were out of date and immediately discarded. The medication trolley was clean and tidy. Emergency equipment such as suction is checked weekly and a written record of this signed. A random stock check of the controlled drug Temazepam was carried out. The correct quantity was accounted for. The residents GP’s have signed for all homely medications administered by staff. Nurses and care staff are doing accredited safe handling of medication training. A system of 6 monthly assessment of competence is starting. The dignity of residents is maintained in a number of ways. Staff knock on doors before entering and bathroom doors are closed. Mail is given to residents unopened and they all wear their own clothing. On the day of the inspection one staff member was preparing to do a dressing in a room with the door open. Care should also be taken to make sure that catheter bags are not visible below clothing. It is recommended that the content of certificates publicly displayed in corridors are reviewed to ensure the dignity of residents is not compromised through this practice. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15. The standard of activity planning and availability is not satisfactory enough to satisfy the social and recreational needs of service users. Menus offer a varied range of nutritious foods but are not always strictly adhered to. Meals are served in pleasant surroundings and special dietary needs and preferences are known by staff. EVIDENCE: The last inspection found that sufficient opportunities to socialise are not available. A new activities coordinator has been appointed and training is to be provided through the care alliance. No activity plans were seen on the day of the inspection and there were no advertised forthcoming events. Where staff have carried out activities, this must be recorded. Activity planning should link directly to identified social needs of residents. Some new activity resources have been purchased. Residents were joined for their meal which was Gammon and Pineapple. The dining area was pleasant and the tables appropriately set. The meal was 15 minutes late in arriving causing some residents to be restless. Staff assisted residents sensitively and discreetly and people appeared to enjoy their meal. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 13 The kitchen was not inspected during this inspection as it was inspected on the 13th March 2005 during an inspection of the adjoining home. A number of areas of concern were identified including unqualified staff preparing meals at weekends, and with no food hygiene training. Menus were not being followed. These issues are being addressed at present. The kitchen is also inspected by Environmental Health Officers. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. Satisfactory procedures are in place and are followed when dealing with complaints. Satisfactory procedures are in place relating to the protection of vulnerable adults. Further external POVA training is recommended. EVIDENCE: There have been three complaints received by the home since the last inspection. A complaints procedure is available to residents and visitors to the home and is publicly displayed. The complaint book was examined and has been filled in correctly by the manager. One additional visit was made by CSCI as the result of a complaint since the last inspection. This was not substantiated. A protection of vulnerable adults policy is available. There is also a whistle blowing policy. Staff questioned were aware of both of these policies. It was recommended at the last inspection that external training such as Local Authority adult protection training be provided. This is being arranged. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 24 and 26. The home is generally warm and welcoming, clean and well maintained. There are suitable washing and toilet facilities and the home is free from offensive odours. EVIDENCE: A tour of the premises was carried out and all communal areas and most bedrooms were inspected. The home was found to be clean and tidy and well maintained. Residents bedrooms are very pleasantly decorated and they have been encouraged to decorate the room with personal effects to make them more homely. Rooms belonging to residents with no relatives have been decorated with the assistance of staff who are keen to avoid the situation that exists in some homes where these rooms are notably bare and less inviting. They should be commended for this. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 16 Some items of furniture in the home are marked and worn. There are numerous styles of chair in some lounges as some have been brought into the home by residents. It can give an untidy impression as some are marked. Where residents bring their own chairs, they must be of a style that can be easily cleaned to prevent the spread of infection. Some carpet areas are marked. It is recommended that portable equipment such as hoists, wheelchairs, and individual slings are placed on a cleaning schedule to ensure they are cleaned regularly. Liquid soap and paper hand towels have been placed in each en-suite bedroom since the last inspection. Laundry facilities are shared with the adjoining home. The laundry system is well organised and residents clothing is clean and smart. A loud noise was intermittent during the inspection and was explained as being caused by an upstairs tap. It was a very intrusive noise and the source must be found and action taken to stop the noise. Fridges in remote dining areas are clean and tidy. Fridge temperatures are taken regularly. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, and 29. There are sufficient numbers of staff on duty to meet the care needs of residents. They are suitably trained to do so. The home operates a thorough recruitment procedure which protects service users. EVIDENCE: Staff rotas were examined and sufficient staff were seen to be on duty. There are waking night staff and occasional spot checks have confirmed that night staff have been alert and caring appropriately for service users through the night. Short staffing is covered where possible, by existing staff working extra hours. The manager attempts to keep new faces to a minimum and attempts to maintain consistency of care. There are sufficient domestic and maintenance staff to keep the home clean and in a good state of repair. Separate laundry staff are employed. Staff files were randomly checked. The most recently recruited staff members file contained all of the required recruitment information. A requirement set at the last inspection said that references sought must be from their most recent employer. These have been obtained but it was acknowledged that another referee may need to be sought if a written reference is not supplied despite chasing the referee. Where this has been the case, the manager said that she always gets a positive verbal reference and will chase the written one which may never be returned. Satisfactory police checks were contained in all of the files checked. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 37 and 38. The home manager is competent to manage the home effectively. The home is run in the best interests of service users and the health and welfare of service users is well protected. There are some areas of imrpovement required particularly in relation to satisfactory record keeping and health and safety monitoring. Staff supervision is not effective. EVIDENCE: The manager continues working towards NVQ level 4 qualification. The manager has been proactive in addressing requirements set at the last inspection. Unfortunately the majority remain outstanding. Where these have not been fully met, some progress is noticeable. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 19 Residents best interests are still compromised due to the tendency for care records to be out of date. There is evidence of auditing and the manager is currently working her way through the records of all residents. Some areas require close monitoring and action to ensure that residents are not put at risk. In particular, it is unacceptable that their continues to be gaps in medication records. This must be closely monitored by the manager and disciplinary action taken if necessary. Nurses must be reminded of their professional responsibilities for administering medication safely. A medicine cup was left unattended in one bedroom. Staff do not receive supervision at least six times per year. This has been an outstanding requirement since June 2004. Immediate action must be taken to remedy this to avoid enforcement action being necessary. It is acknowledged that some staff have been supervised and that some progress has been made. Steradent was found in the en-suite of one resident. It may be that this was brought in by relatives. If this is the case it is recommended that staff explain the dangers associated with effervescent tablets to relatives. There is an outstanding recommendation that toggles should be fitted to all light pull cords. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 x 3 x x 3 x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x x x x x 3 2 Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7, OP8 Regulation 15,17 Requirement Care plans must be evaluated at least once per month. Assessment tools must be kept up to date and accurately reflect the status of the service user. When assessment tools indicate a high area of risk (Waterlow) this must lead to the generation of a care plan to address the problem. OUTSTANDING Staff must receive formal supervision at least 6 times per year. OUTSTANDING SINCE 30/06/04 Fire doors must not be chocked open. Steradent must be locked away unless a suitable risk assessment has been completed. OUTSTANDING SINCE 30/11/04 Residents must have the opportunity to be suitably stimulated. OUTSTANDING SINCE 30/11/04 Marked chairs must be replaced or cleaned. Carpets must be clean. Chairs must be of a suitable fabric to enable effective cleaning. The cleaning of reusable equipment such as hoists, slings, wheelchairs and ambulifts must Timescale for action 01/07/05 2. OP36 18 01/07/05 3. OP38 13, 23 Immediate 4. OP12 16 01/07/05 5. OP19 23 01/07/04 6. OP26 23 16 01/07/04 Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 22 be added to cleaning schedules. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP28 OP31 OP26 OP38 OP10 Good Practice Recommendations The home should continue towards working towards the standard of having 50 of care staff qualified to NVQ level 2 by 31/12/05 The manager should continue working towards NVQ level 4 Plastic toggles should be fitted to all light pull cords Risk assessments should be carried out where residents have glass china cabinets. Certificates displayed in communal areas of the home should be reviewed and those relating to intimate care of residents replaced with more genral ones. Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 23 Commission for Social Care Inspection Northumbria House Manor Walks Cramlington, Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kensington B53-B03 S409 Kensington V220891 260405 Stage 4.doc Version 1.20 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!