Inspection on 11/08/05 for Kensington Lodge

This inspection was carried out on 11th August 2005.

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 10/01/06

Kensington Lodge 14/03/05

Kensington Lodge 27/10/04

Similar services:

Coopers Mill Ltd

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Paradise Lodge

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Upaya Ananda

Newton Court (1-2)

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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 Marilyn Fellingham Unannounced 11 August 2005 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Kensington Lodge Address 5 Cabbell Road Cromer Norfolk NR27 9HU 01263 514138 01263 514138 trudy56@btopenworld.com Mr Robert Stanley Hann Mrs Trudy Jane Hann Mr Robert Stanley Hann Care Home 15 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) Category(ies) of Learning Disability (15) registration, with number of places Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14 March 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 I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours. Opportunity was taken to tour the premises and examine care and staff records. The Inspector, including those staff members who were on duty, spoke to all thirteen residents. The Manager /Provider and deputy manager were present for the inspection process. What the service does well: What has improved since the last inspection? A complete restoration of the back of the house has taken place with all new windowsills; a new patio area has been installed. The kitchen has totally been revamped; new furniture has been purchased for the downstairs hall area. A new bath and toilet has been installed upstairs with new flooring and tiling. New fire doors have been fitted in the basement and laundry room. An Otex system has been added to the laundry system that helps combat infections such as MRSA. Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 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 I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 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 standard(s) 5 The Provider supplies a suitable written contract for each service user that enters the home, however they do lack significant information pertinent to the service users. EVIDENCE: The Provider/Manager discussed the procedure for admission to the home and stated that all residents are given a contract and conditions of residency; examples of these were seen and they contained all details of residency and service provision, however they did not allude to the fees and a recommendation is made. The contracts also lacked dates of when they were produced and they also were without signatures. Those residents able to confirmed that they had had these. The Manager also confirmed that those residents who are unable to read have these contracts explained very carefully so that they have some understanding of the content. Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 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 standard(s) 6,10 The care planning system needs to be improved to provide clear guidelines of care for the residents and the staff. The residents are aware that information about them is handled appropriately. EVIDENCE: Individual care plans were reviewed, these were not clearly set out and did not contain evidence of regular review and a requirement is made. The care plans also do not contain records of individual service user’s social activities and a recommendation is made. The care plans need to be more compact and records kept of untoward occurrences. Evidence exists of risk assessments and these are detailed and good. The service user’s records had records of regular weight reviews. Those staff spoken with, acknowledged the need for respecting information about the residents and were aware of the need for confidentiality. They confirmed with the Inspector that this is covered in their induction. Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 11,14,16 Service Users are given opportunities for personal development and to take part in leisure activities. EVIDENCE: Discussion with staff, the management and the residents revealed that the residents were given every opportunity to engage in leisure activities and pursue their personal development. The residents talked about going swimming, riding, sailing and belonging to a local club for persons with learning disabilities. Some said that they belong to a bible class, another one attends a women’s health club; nine residents went on holiday to the Isle of Wight and that it was of their choosing and that they were busy planning where to go next year. Some of them join cluster groups to learn how to cook and one attends a group called Posh Puddings for Harrods. Many of the residents who are able do supported employment on a Saturday; one goes to Easton Agricultural College. Many more activities are offered and the residents were very clear about being able to “say no” if they did not want to do something. Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 Page 11 Two of the residents have got married and the home did everything they could to make this an enjoyable occasion not only for the happy couple but also all the residents and family members who attended the ceremony. The residents were very enthusiastic about this and the Inspector was invited to look at many photographs to confirm this. All the staff have enabled this couple to develop socially and emotionally with various in put from interested professionals. Numerous residents invited the Inspector, as they arrived home in the evening, to look at the work that they had produced that day. There was a lively atmosphere in the home on their return, an indication that they all had had a satisfactory day pursuing their activities. Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 20 If appropriate service users handle and administer their own medication, they are protected by the home’s policies and procedures. EVIDENCE: The Inspector reviewed the policies and procedures in place for handling and administering medication. Risk assessment documentation was in place to ensure that if a resident wished and was able to self medicate they would be able to do this safely; no one at the moment self medicates and it is their wish not to do so. A fridge has been contained to store medication in at certain temperatures this was recommended at the last inspection. Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 Page 13 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 standard(s) no standards inspected. EVIDENCE: Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 24,27,28,30 Service users live in a well-maintained and safe environment. The bathrooms and toilets provide sufficient privacy; there are sufficient shared spaces to meet the service users needs. EVIDENCE: The home appears safe, well maintained and suitable to meet the service user’s needs. At the time of inspection it was evident that appropriate fire and health and safety practices were being observed. The Inspector noted that areas of concern highlighted in the recent fire inspection report had been addressed. The bathrooms upstairs have been redecorated and tiled and provide adequate privacy and meet the needs of the service users. The service users have access to a variety of communal spaces including a seating area outside. The dining room is bright and provides suitable seating arrangements for all the residents. Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 Page 15 The entrance hall has some new fire retardant furniture this was recommended in the fire inspection report; the residents do like to sit in this area as well as the other communal rooms. The home appeared clean and hygienic throughout. Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,34 Service users benefit from the understanding that the staff have of their roles and responsibilities; the staff are competent to carry out their roles. EVIDENCE: The staff are well rehearsed in their appropriate roles, evidence was seen to support this and the files reviewed confirmed this. Job descriptions are in place with clearly defined roles for all staff, these set out the principle responsibilities. Staff contracts were also seen, staff training records, and CRB checks were found to be up to date. Staff training records indicated that the staff in post had received training appropriate to the job that they were employed to do. Those staff spoken to confirmed that they felt that the training that they had received was relevant to their roles within the home. Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,40,4142,43 Service users benefit from a well managed home where their safety and welfare is promoted and protected. EVIDENCE: The Inspector gained the impression that the service users benefit from this well run home; unfortunately the Manager’s management course has been put on ‘hold’ as there is a shortage of tutors for the course and has caused much frustration as the home is keen to comply with all standards. The home seeks to promote the health, welfare and safety of the residents; this was identified by the response to fire inspection reports, training records, and discussion with the service users. All the residents are encouraged to visit their GP’s and seek health promotion advice when required; one resident was being taken to the GP at the time of inspection. Policies and procedures are in place and these have been up dated to comply with current practice and research. Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 Page 18 Accidents and incidents are well recorded, however they do need also to be recorded in individual plans of care and a recommendation is made: maintenance records were inspected and matched those projects that had been carried out and seen by the Inspector. Records seen indicate that the care is monitored and quality issues addressed; audit report seen and another one is being completed for the end of this year. Reports are made on health and safety, infection control and security, cleaning of the home and maintenance. It is recommended that a resident survey be carried out in order to ascertain if the home is meeting the needs of the residents and addressing all quality issues appropriately. The home has appointed its own fire officer who will do all the internal training for staff and also guide the home’s owners as to their responsibilities in relation to fire and health and safety. The latest report carried out by this person was seen by the Inspector. Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 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 3 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 3 x 3 Standard No 11 12 13 14 15 16 17 4 x x 3 x 3 x Standard No 31 32 33 34 35 36 Score 3 3 x 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kensington Lodge Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 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. 1. Standard 6 Regulation 15 Requirement The registered person shall prepare a written plan as to how the service users needs in respect of his health and welfare are to be met and keep the service users plan under review. Timescale for action Immediate and on going 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. Refer to Standard 5 6 Good Practice Recommendations It is recommended to ensure best practice that the service users contracts highlight fees and are dated and signatures added. It is recommended that all care plans contain notes on untoward incidents. Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Kensington Lodge I55 S27315 Kensington Lodge V243723 110805 Stage 4.doc Version 1.40 Page 22 - 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. 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