Inspection on 10/01/06 for Kensington Lodge

This inspection was carried out on 10th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kensington Lodge 02/03/09

Kensington Lodge 14/11/06

Kensington Lodge 11/08/05

Kensington Lodge 14/03/05

Kensington Lodge 27/10/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Kensington Lodge 5 Cabbell Road Cromer Norfolk NR27 9HU Lead Inspector Mrs Marilyn Fellingham Announced Inspection 01:00 10 January 2006 th Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kensington Lodge Address 5 Cabbell Road Cromer Norfolk NR27 9HU 01263 514138 01263 514138 trudy56@btopenworld.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) Mr Robert Stanley Hann Mrs Trudy Jane Hann Mr Robert Stanley Hann Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th August 2005 Brief Description of the Service: Kensington Lodge is a large, period residence located close to Cromer town centre and sea front. The care home is registered to accommodate 15 service users in the category of People with Learning Difficulties. Service user accommodation is spread over 4 levels, with communal rooms on the ground and first floor. There is a stair lift to the first floor only, so service users with rooms on the floors above must be sufficiently able bodied to manage the stairs. There is a fire escape route, approved by the fire officer, from the upper floor through to an adjoining property. To both front and rear, the property includes small paved areas with seating and flower tubs, but lacks a garden or car park. However, rooms to the rear of the building benefit from views of the esplanade and a putting green and other seaside attractions together with the main shopping area are within walking distance. Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place over four and a half hours. A tour of the home took place and care and staff records were inspected. The manager was present with her deputy for the inspection and the Inspector spoke with all the service users and the staff that were on duty. What the service does well: What has improved since the last inspection? Care planning has improved since the last inspection although there is still need for improvement. Many areas and rooms have been refurbished and damp walls have been treated and re decorated. There is now more involvement by the service users with the cooking of meals. Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 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. Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 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 Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 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): No standards inspected. EVIDENCE: Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 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): 6,7,8,9,10. A big improvement has taken place in relation to care planning. Service users are enabled to control their own lives. EVIDENCE: Individual care plans were reviewed; these were much improved with clearer guideline for staff to follow. It was also evident that there had been service user involvement with the care planning process. The care plans also reflected that the service users make decisions about their lives and aspirations. The Inspector witnessed a number of service users making decisions about what they were going to do that evening and what time they would be returning to the home. It was noted that the care plans contain risk assessments and that the residents are allowed to risks as part of their continued development. The care plans indicated the amount of involvement needed and the risks. The Inspector chatted with one service user who had recently been admitted to the home; she explained that she could go out on her own, but she rings the home to always advise them of her whereabouts. This risk assessment and care Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 Page 10 plan is done in conjunction with the social worker and part of a rehabilitation programme to meet the needs of this particular individual. The residents are consulted about changes made within the home and decisions about where they would like to go on holiday. Minutes were seen of these meetings. The Inspector noted that during her visit a painter and decorator was in the home and a number of service users had been instructing him about what colours they would like their rooms painted. The residents are also consulted informally who is going to live with them and they quite readily voice their opinions. All aspects of confidentiality are covered in the induction process for new staff; staff members and staff records confirmed this. Staff members were aware that there are some aspects of information that has to be imparted to the manager; a scenario was given to the Inspector to highlight this. The policy for confidentiality was seen by the Inspector and all new staff are made aware of this. Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 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): 12,13,15,17. Service users are given the opportunity to live a fulfilled life. Preparation of meals is handled well. EVIDENCE: Individual care plans indicated that service users are encouraged and supported to develop their social, emotional, communication and independent living skills. Discussion with the residents confirmed that they participated in appropriate activities and mixed with other people other than those living and working in the home. A number of the residents pursue part time educational courses and their certificates for these were seen on display in their rooms. It was observed by the Inspector that there was great comradeship amongst all the service users with one of them interpreting for someone who had difficulty with their speech. There was great laughter and all of them wanted to share with the inspector what they had been doing all day. A lot of discussion takes place about meals and those who are able now help with the preparation. The manager has asked a dietician to visit the home to Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 Page 12 ensure that the residents are getting adequate well-balanced meals. They monitor weights regularly. Examples of the menus were seen and these are presented in a picture format, large print so that all the residents can understand and make choices about their food. Many of the residents go home for weekends; some are taken out to lunch by their relatives. The Inspector was party to a conversation where a number of service users were discussing their pending visit to the cinema that evening. Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 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): 18,19,21. The service users physical and emotional care needs are met and their aging and illness is treated with respect. EVIDENCE: The care plans and daily reports indicated that the residents attend various health care clinics, staff initiate GP visits and visits to the dentist and opticians. A representative from the local surgery is making a visit to inform the service users and the staff what health care facilities are available that the service users can utilise. One of the residents attends a special therapy clinic. Ageing and illness is dealt with in a most satisfactory way, in fact care notes indicate for one resident who is terminally ill that she is so well looked after that some of the extra care provided is now not necessary. This particular service user has been provided with a special bed and is visited by the community nurse. One resident who had aged considerably had her needs re evaluated and after discussion with other professionals it was decided she would be better off in a home where her needs could be adequately met: she has settled well in her new home and the staff still visit her. Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 Page 14 Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 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): 22,23 Arrangements for dealing with complaints and concerns are satisfactory. Service users appear to be protected from abuse. EVIDENCE: The Inspector noted that there was a comprehensive complaints procedure that was also in picture form for the service users so that they had a clear understanding of how to make a complaint; those residents when asked confirmed that they understood what they had to do if they had a concern and that they would happily go to anyone of the carers and the manager. The complaints documents were seen and had been responded to in the appropriate time as indicated in the home’s procedure for complaints. A policy is in place for all matters relating to the protection of vulnerable adults. One allegation of an abuse incident had been made by one resident, about another resident; all documentation was seen concerning this. All levels of professionals had been informed and full records made of the action taken and new risk assessments put in place. It is planned for the future for all staff to have sessions covering the Protection of Vulnerable Adults. Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 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. 30. Service users live in a well-maintained and safe environment. The home is clean and hygienic. EVIDENCE: The home appears safe and a considerable amount of maintenance work has been carried out and more was taking place; this was noted during a tour of the home. Many of the service users bedrooms had been decorated and these appeared homely and comfortable. The service users all commented that they liked their rooms and that they were pleased with them. Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 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): 33,35,36. Service users benefit from a well run home and are supported by an effective staff team. EVIDENCE: Staffing rotas were examined and the deployment of staff is adequate to meet the needs of the service users. One extra member of staff is always on duty to support the service user who is terminally ill. This particular service user felt she was very well cared for and that all her needs were met. Agency staff are not used which ensures continuity of care and not disrupt the service users. However on some occasions staff are doing some extra duties to cover those staff who appear not to be fully committed. The training plan for 2006 was seen, this included sessions on first aid, food hygiene and POVA. Training is taking place in relation to someone who has a multiple personality so that their needs can be met by all members of the staff team. Supervision sessions take place and records for these were seen; they highlighted training needs and professional development. Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 Page 18 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): No standards inspected. EVIDENCE: Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x x x x LIFESTYLES Standard No Score 11 x 12 4 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score x x 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kensington Lodge Score 3 3 x 3 Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000027315.V262875.R01.S.doc Version 5.0 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kensington Lodge DS0000027315.V262875.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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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