Inspection on 22/05/07 for Kenwood

This inspection was carried out on 22nd May 2007.

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

Kenwood 06/08/08

Kenwood 07/11/06

Kenwood 23/05/06

Kenwood 25/10/05

Kenwood 04/04/05

Kenwood 28/09/04

Kenwood 28/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Kenwood 30-32 Alexandra Grove Finchley London N12 8HG Lead Inspector Daniel Lim Key Unannounced Inspection 22nd May 2007 09:30 X10015.doc Version 1.40 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 Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kenwood Address 30-32 Alexandra Grove Finchley London N12 8HG 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) 020 8445 5112 020 8343 7992 New Century Care (Finchley) Limited Mr Najm Mudhoo Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 Specific service users. 2 Specific service users who are under 65 years of age, one of whom also has a learning disability, may continue to be accommodated in the home. This condition must be reviewed at such times as either of the service users attains 65 years of age or vacates the home. Three specified service users who have dementia may remain accommodated in the home. The home must advise the registering authority at such times as any of the specified service users vacates the home. 7th November 2006 2. Date of last inspection Brief Description of the Service: Kenwood Nursing Home is owned and managed by New Century Care (Finchley) Limited. The home has a mission statement, which says that it aims to provide good quality accommodation, nursing and personal care for vulnerable elderly people, who as a result of loneliness, physical disability or illness are seeking an understanding and caring environment. The home is a three storey detached house. There are two lifts between the ground and first floor, which are areas occupied by service users. The third floor has a staff room and storeroom. There is a communal dining room on the ground floor and a lounge on each floor. A small activity room is located on the first floors. There are 22 single bedrooms and 5 shared bedrooms. All the bedrooms have en-suite facilities. There is a small parking area at the front of the building and a large garden at the rear with wheelchair access. The home is situated in a residential area and close to a variety of shops, restaurants and transport facilities located along Ballards Lane, North Finchley. The fees charged by the home range from £550 - £800. The provider must make information about the service available (including reports) to service users and other stakeholders. The home has applied to vary it’s registration to allow it to accommodate residents with dementia on the first floor. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on 22nd & 25th May 2007. The inspection took a total of five and a half hours to complete. The second visit on 25 th May 2007 was made to view documents not available on the first day. The inspector found that the previous requirement made had been complied with and the quality of care provided was satisfactory. During this inspection, the inspector was accompanied by the manager of the home (Mr Najm Mudhoo) and the company’s area manager (Ms Helen Bennet). The inspector was able to interview three residents and two relatives. The feedback received from them indicated that they were generally satisfied with the care and accommodation provided. Statutory records were examined. These included four residents’ case records, the maintenance records, accident records, complaints’ record, financial records and fire records of the home. These records were well maintained. The premises including bedrooms, bathrooms, lounges, treatment room, kitchen, garden, laundry and communal areas were inspected. These areas were clean and well maintained. A total of six staff on duty were interviewed on a range of topics associated with their work. Staff records, including supervision records, staff rota, evidence of CRB disclosures, references and training records were examined. Staff on duty were noted to be knowledgeable. The minutes of staff and residents’ / relatives’ meeting were also examined. What the service does well: The home was clean and well furnished. Maintenance records had been kept up to date. The bedrooms appeared homely. The home had a large garden which was attractive and accessible to residents. Residents indicated that they had been treated with respect and dignity. The home had a comprehensive training programme for staff. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 6 Residents were satisfied with the meals provided and kitchen staff had a good understanding of the dietary preferences of residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Satisfactory arrangements were in place to ensure that residents’ aspirations and needs are assessed. This ensures that their needs can be identified and met at the home EVIDENCE: The three residents and two relatives who were interviewed indicated that residents were generally well cared for and their care needs had been met at the home. Comments made by them included, “happy with the care provided,” “well cared for” and “I am quite satisfied with the care provided”. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 9 A sample of four residents’ case records which were examined, contained comprehensive assessments (including pre-admission assessments). Risk assessments (such as risk of falls and pressure sores) together with strategies for minimising risks had been prepared. Residents in the home were noted to be clean, appropriately dressed and appeared well cared for. The manager stated that the home does not provide intermediate care. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for health and personal care were found to be satisfactory. This ensures that residents’ healthcare, personal, cultural and social needs are attended to. Residents interviewed were satisfied with the arrangements. EVIDENCE: The three residents interviewed, indicated that their healthcare needs had been met. Comments made included, “ seen the doctor”, “I have been given my medication” and “ can see the doctor when I need to”. The sample of four case records examined were up to date and plans of care had been reviewed monthly. Records of healthcare appointments and Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 11 treatment were documented. A record of GP visits and medication reviewed had been maintained. The arrangements for the administration of medication were satisfactory. A record of the temperature of fridge and treatment room had been maintained. Medication administration charts (MAR charts) had been appropriately signed. Residents were able to confirm that they had been given their medication. The records of a resident with a pressure sore contained a pressure area care plan. Monitoring charts had been provided and the tissue viability nurse had been consulted regarding pressure area care. It was noted that two residents admitted into the home about 5 weeks ago had not been seen by the GP. The manager explained that the GP had refused to attend to these two residents. A complaint had been made to the health authority concerned and the home had arranged for these two residents to be registered with a different GP. There was documented evidence of this. The manager further stated that an appointment had been made for the GP to visit the two residents concerned. Documented evidence was available. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for the daily life and routines of residents were on the whole, found to be satisfactory. This ensures that residents have access to a range of activities and their dietary, cultural and social preferences are met. Improvements are however, recommended in the provision of social activities. EVIDENCE: The daily activities programme was on display in the reception area. Activities provided included exercise sessions, video, discussion, art and crafts, games and outings. It was noted that no activities were provided during the morning of this inspection. The manager explained that the activities organiser did not start work until the afternoon. To ensure that residents have access to social and Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 13 therapeutic activities in the mornings, a recommendation is made for the registered person to review the provision activities and ensure that residents are provided with appropriate social and therapeutic activities during the mornings. Residents who were interviewed stated that they had been visited by their relatives. Two relatives were present during this inspection. The kitchen was clean. The menus examined appeared varied and balanced. A record of daily temperatures for the fridge and freezer had been kept. These were satisfactory. Residents interviewed indicated that they were satisfied with the meals provided. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for responding to complaints and for adult protection were satisfactory. This ensures that residents are well treated and protected from abuse. EVIDENCE: The complaints folder was examined. No complaints had been recorded since the last key inspection of the home. The manager explained that none had been received. The manager and his staff when interviewed, were aware of the procedure to follow when responding to allegations of abuse. There was documented evidence that staff had been provided with adult protection training. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 15 Residents who were interviewed indicated that they had been well treated by staff. The issue of equalities and diversity was discussed with the manager and his staff. Staff indicated that they had been instructed to treat all residents sensitively and with respect regardless of disability, gender, race, religion or sexual orientation. The home had an equalities and diversity policy and procedure. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 21, 22, 23, 24, 25, 26 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home was clean and furnished to a high standard, therefore providing a pleasant environment to live in. Residents were pleased with their accommodation. EVIDENCE: Residents interviewed stated that they were happy with the accommodation provided. Bedrooms inspected had been personalised by residents concerned and appeared homely. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 17 The premises were inspected and found to be clean and cheerfully furnished. No offensive odours were detected. The laundry was inspected and the laundry assistant who was interviewed was aware of the arrangements for the laundering of soiled linen and the need to wash it at a temperature of at least 65C for a minimum of 10 minutes. The home was well maintained. Safety inspections had been carried out on the portable appliances, lift and hoists, gas installations and electrical installations. Documented evidence was available for inspection. The gardens were attractive, colourful and seating had been provided. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 18 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing arrangements were on the whole, satisfactory. This ensures that residents are well cared for. Two deficiencies were noted and requirements have been made for these to be rectified. EVIDENCE: The six staff who were on duty were interviewed on a range of topics associated with their work (such as fire safety, adult protection, care of residents with dementia, equality & diversity and team work). They were noted to be knowledgeable regarding their roles and responsibilities. They stated that they had been instructed to treat all residents with respect and dignity regardless of their race, religion or sexual orientation. This was also confirmed in the induction programme of staff which was examined. Residents who were interviewed confirmed that staff were respectful towards them. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 19 The duty rota was examined. This indicated that in addition to the manager the following staff were on duty Am - 7 staff (including 2 nurses) Pm – 6 staff (including 2 nurses) Night – 3 staff (1 nurse) Two staff indicated that the staffing levels were not always adequate. They explained that a large number of residents in the home require a high level of care. This was confirmed in information provided in the pre-inspection questionnaire of the home. The issue of staffing levels was discussed with the manager and area manager (who was present for part of the inspection). In view of the concern expressed, a review of staffing levels is required. This must be done in consultation with residents and staff. Documented evidence of this is required. The training records examined, indicated that staff had been provided with the required training (such as health & safety, care of residents with dementia, moving and handling, food hygiene and adult protection). With one exception, recruitment records examined indicated that the required recruitment procedures (including obtaining of satisfactory CRB disclosures and references) had been followed. One staff record examined did not have two satisfactory references. One of the two references (employer’s) did not have the address of the referee. This was brought to the attention of the manager who agreed to request that a second suitable reference or address of the employer concerned be provided. A requirement is made accordingly. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 20 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home was run in the best interest of residents and satisfactory arrangements were in place to ensure the safety and welfare of residents in the home. EVIDENCE: The registered manager was a trained nurse and had a degree in management. He was knowledgeable regarding his responsibilities and the needs of residents. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 21 . There was evidence that staff and residents meetings had been held. The fire logbook was examined. Weekly fire alarm tests had been carried out and documented evidence was provided. Fire drills and fire training had been documented. The fire risk assessment had been updated. A recent inspection carried out by the LFEPA (in Feb 2007) was noted to be satisfactory. Windows inspected had been fitted with window restrictors. These were engaged. The home had a current certificate of insurance. The accounts of three residents whose money was kept by the home were examined and noted to be satisfactory. The home had an effective quality assurance and monitoring system. A recent consumer survey report of the services provided by the home was available for examination. This was positive and the satisfaction level high. . Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 22 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. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 X 3 X X 3 Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP27 Regulation 18(1)(a) The registered person must carry 30/07/07 out a review of staffing levels and the deployment of staff to ensure that the care needs of residents are met. This must be done in consultation with residents and staff. 2 OP29 19(1) The registered manager must 30/07/07 ensure that a second suitable reference or address of the employer concerned be obtained for the staff member identified to him. Requirement Timescale for action Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 24 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 OP12 Good Practice Recommendations The registered person should review the provision activities and ensure that residents are provided with appropriate social and therapeutic activities during the mornings. Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kenwood DS0000010457.V333461.R01.S.doc Version 5.2 Page 26 - 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!