Inspection on 03/08/05 for Kenwyn

This inspection was carried out on 3rd 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

Kenwyn 10/01/07

Kenwyn 08/02/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Kenwyn Albert Road Crediton Devon EX17 2BZ Lead Inspector Rachel Doyle Announced 3 August 2005 rd 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. Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kenwyn Address Albert Road, Crediton, Devon, EX17 2BZ 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) 01363 772670 01363 772670 Welling Ltd., 6 Beaufort West, Bath, Bath & N. E. Somerset, BA1 6QB Mrs Alison Watson Care Home 25 Category(ies) of OP - Old Age (25) registration, with number of places Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16/12/04 Brief Description of the Service: Kenwyn is a long established residential care home for older people situated close to the centre of the market town of Crediton. Kenwyn consists of an original 1930s two storey building on split-levels with a modern extension to the rear and a more recent extension on the west side. It became a home for older people during the 1960s. There is level access into the modern extension through the car park entrance. The original building and its extension combine to form a layout which has a ground, mezzanine and first floor. The home has bedroom accommodation on all floors some of which have en-suite toilet facilities. All floors are accessible by passenger lift. Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection since the Home changed owners in April 2005. The inspection was announced and took place from 10.00-14.15. The inspector was able to meet with the new owner for part of the morning with the new manager being available for discussion throughout the inspection. There were 21 residents in occupation and 2 vacancies as two doubles are currently used as singles. The inspector was able to move freely around the Home and had access to all relevant documents. The inspector spoke to the manager, one staff member and 7 residents in depth and took lunch with residents in the dining room. CSCI received one comment card from a relative who said that there were ‘good signs so far on improvements by the new owner’. It was a lovely sunny day and some residents had been out or for a walk. What the service does well: What has improved since the last inspection? The Home has worked hard to formalise staff recruitment and training, including a TOPSS induction programme. Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 6 The Home has purpose built medication and document storage. Corporate policies and procedures have been individualised to relate to the Home. They are comprehensive and staff had signed to indicate that hey had read them. Doors were not wedged open and the appropriate devices had been fitted to allow resident choice. Care plans were comprehensive, giving clear guidance on how to meet individual needs and involved relatives. The complaints procedure and issues/concerns book ensured that residents concerns were addressed and actioned. Staff supervision sessions are underway for all staff following a long period of informal communication. These included excellent explanations of the objectives of these meetings. The Home continues to make environmental improvements. 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. Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 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 Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 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) 2, 3, 4, 5, 6 Residents benefit from good admission and assessment practice, which ensures that the Home is able to meet their needs. EVIDENCE: The Home currently has different methods of giving residents information via a contract and letter depending how residents are funded, local authority (LA) or self. Those who are LA funded receive information about terms and conditions. Care assessments were seen. The Home has a comprehensive computer programme, which includes a Resident Dependency and Age profile. The manager said that the staff team is also considered when admitting residents. The manager goes out to assess potential residents whether at home or hospital and ensures that any rare emergency admissions are assessed on the day of referral as possible. Residents spoken to all said that they felt that their needs were met. The Home looks at dependency levels weekly and the manager is able to top up staff independently to ensure that residents’ needs are met. The Home would provide respite if their was a vacancy. Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 9 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, 10 The health needs of residents are well met with evidence of good multidisciplinary working taking place on a regular basis. Independence is clearly promoted and although privacy and dignity is generally very well maintained slight improvements could be made. EVIDENCE: Three care files were looked at. These were clear, comprehensive and contained all issues identified in the assessment. Relatives had been involved in the assessment, medical visits were clearly documented and risk assessments were complete. One resident said that ‘they care for me like in my plan, which I have seen’. Excellent activities and personal history sections were seen. All residents said that they were able to access health services via staff. One staff member had noticed that a resident couldn’t read their name badge and had arranged for an optician appointment. All residents have been assessed by the continence promotion nurse and equipment provided individually. There was various pressure-relieving equipment throughout the Home as necessary. The manager said that the local District Nurse undertakes all clinical procedures. Carers are able to liaise with the District Nurse to work towards competence to dress minor wounds. One resident said that they had had a lovely bath and that the carer had painted their nails for them. Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 10 Independence is clearly promoted and documented. The hairdresser had visited the Home the day before. Throughout the inspection many residents were addressed by some staff as ‘darling’ and ‘my lovely’. Two residents commented negatively on this aspect of care. Communal toiletries were seen in two bathrooms. There is a policy on privacy and dignity and residents confirmed that staff knock on doors before entering and treat them well. There are records of all phone messages and some residents have private telephones. Medications were looked at and records were correct. Medication is stored correctly. Care plans reminds staff if any resident needs assistance with administration and staff ensure that medication is taken before signing. The Home has submitted a medication policy to the pharmacy inspector. Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 11 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, 14, 15 Social and leisure needs and meals are well managed at the Home. EVIDENCE: The Home are currently assessing residents and developing a four weekly activities programme with an allocated carer. The manager is working through residents on a one-to-one basis and has taken some out for coffee to ascertain any preferences. There has been a recent sing-along, weekly Tai Chi, regular external entertainers and craft sessions. Residents proudly showed the inspector objects, which they had glass painted the previous day. Residents are able to opt out as they wish. Residents all felt that they were able to see their friends and relatives as they wished. One relative commented within the comment card that they were satisfied with the overall care. Residents were seen to walk around the Home as they wished. One resident had popped down to the library and for a walk that morning. The dining room has recently been attractively decorated. There are clear menus and residents said that they enjoy the food, which was home-cooked and nutritious. Condiments, alternatives and seconds were available. Staff were very attentive to residents during the meal. Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 12 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, 18 Residents are well protected from harm or abuse and are confident that they are listened to and their requests actioned. EVIDENCE: The Home now has an ‘issues and incidents book’. All verbal concerns are recorded and treated formally. Actions and outcomes were very clear. The manager said that it was useful to identify any patterns or issues, which the Home could then address. Residents said that they felt that they were listened to and that staff were approachable. There is an accessible and comprehensive complaints policy. There is now an excellent Protection of Vulnerable Adults policy, which includes whistle blowing. This includes the correct procedure for informing other agencies and documentation. The manager has the Alerters’ Guide and is organising formal POVA training. Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 13 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, 20, 23, 24, 25, 26 The environment is clean and well maintained providing residents with a homely and attractive place to live, which meets their needs. Relevant documents need improving to ensure that this remains the case. EVIDENCE: The home complies with fire and environmental heath requirements. The Home is located close to the centre of Crediton, situated at the end of a cul-de-sac. It is accessible and safe, designed to provide a homely environment. Residents were seen to be using the upper television lounge where coffee is served to encourage socialising. Residents can access the outside from each floor. There are two other quiet seating areas in addition to the conservatory. The Home is tidy and well maintained. There is a maintenance book where staff put in jobs to be done. The maintenance man had ensured that these were attended to in very good time. There is a maintenance programme, which responds to family comments/suggestions. All residents’ rooms were as they wished them to be and personalised. The Home is in the process of offering and fitting locks. Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 14 The commode waste sink is still in the laundry room. There is no clear policy on commode waste disposal. The laundry itself was clean and clutter free. Staff are aware of the washing sluice facility. Residents have individual clothes baskets. There were plenty of gloves, goggles and aprons. Staff were seen washing their hands and there were no offensive odours throughout the Home. Staff were clear on infection control issues and the manager said that they use universal procedures and were aware of MRSA procedures. The Home smelt lovely and residents said that this was normal. Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 15 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, 28, 29, 30 Resident’s benefit from having skilled, experienced staff that have a good understanding of their needs via a robust recruitment procedure. EVIDENCE: There have been no significant changes in the staff team following the change of management. At the time of the inspection there was the manager, assistant manager, two carers and three domestics on duty. Staff said that they had regular staff meetings, minutes were seen. The manager felt that the staff team were very good and had improved in formalising care and that they had coped very well with the recent changes. The new maintenance man works 10 hours a week. Three staff recruitment files were looked at and were complete. Volunteers are rarely used but there is a robust policy. Four staff have NVQ 3, four staff are undertaking NVQ 2 and one NVQ 3. One staff member will start NVQ 4 this year, which will result in 75 staff achieving an NVQ qualification by the end of the year, which is commendable. There is a checklist of mandatory training, which is all up to date and a corporate training plan. The induction follows TOPSS. Three new carers are currently being recruited and another senior to follow. Residents felt that there were enough staff to meet their needs. Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 16 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) 36, 37, 38 Slight improvements need to be made to ensure that residents are cared for in a safe environment. EVIDENCE: All staff have now had a formal staff supervision session with a supervision explanation and supervisor/supervisee agreement. This role will be delegated to senior staff. The policies folder was looked that. These appeared to be comprehensive and had been adapted from Croner so that they were individualised to the Home. Staff had signed each policy to say that they were read. The Home was not using door wedges and had fitted automatic fire door closers to appropriate doors to allow for safe opening. There is an excellent emergency information pack for the fire brigade available with an evacuation list. Fire equipment is checked. All radiators have been risk assessed. Twenty have been covered including all corridors and communal areas, others are low risk or obstructed by furniture. The Home has two in-house Manual Handling Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 17 Trainers and there is a minimal lifting policy. The water is excessively hot in one bath and some basins. The Home has a risk assessment approach and water temperatures are sampled every week from different taps. The new provider said that they had been led to believe that all baths had thermostatic regulators fitted and will be fitting one to the bath mentioned above. There is a bathing policy. Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x 3 3 2 Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 19 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 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. 1. 2. 3. 4. Refer to Standard 10 26 38 Good Practice Recommendations It is recommended that staff address all residents by their preferred form of address and that communal toiletries are not used in any bathrooms. It is recommended that the Home devises a policy dealing with the use of commodes and disposal of waste in the laundry room. It is recommended that an appropriate device be fitted to the dining room door to allow residents and staff to be able to hold it open for safe access. Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Exeter Office, Suites 1 & 7 Renslade House Bonhay Road EXETER, EX4 3AY 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 Kenwyn D54-D06 63516 Kenwyn 234617 030805 Stage 4.doc Version 1.30 Page 21 - 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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