Inspection on 08/02/06 for Kenwyn

This inspection was carried out on 8th February 2006.

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

The inspector 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 03/08/05

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, Crediton Kenwyn Albert Road Crediton Devon EX17 2BZ Lead Inspector Rachel Doyle Unannounced Inspection 12:00 8 February 2006 th 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 Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 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. Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kenwyn, Crediton Address Kenwyn Albert Road Crediton Devon EX17 2BZ 01363 772670 01363 772670 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) Welling Ltd Mrs Alison Watson Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd August 2005 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, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Wednesday 8th February 2006 from 12.00-14.45. The Registered Manager is now based in another Home owned by Welling Ltd and visits Kenwyn approximately once a week. The Home are about to put in an application to CSCI for another manager to be Registered. The inspector was welcomed by an Assistant Manager and was able to discuss any issues with them. There were 23 residents at the Home and 1 vacancy, the Assistant Manager, 5 carers and the cook and maintenance man. The inspector spoke to 8 residents in depth, taking lunch with a number of residents, toured the Home freely and looked at any relevant records. The Home has recently made a number of environmental improvements such as re-decorating the entrance hall, including a fish tank and replacing furniture (beds, chairs and bedroom furniture as required), many carpets and are currently re-decorating the dining room, which will be out of action for three weeks. Residents had been consulted and are having meals in the upstairs lounge or in their rooms during this time. An administrator is now employed for two days a week. What the service does well: What has improved since the last inspection? A policy dealing with the use of the commode waste disposal, which is not ideally situated in the laundry has been drawn up and is being followed. Privacy and dignity is generally well maintained but more thought should be given to preferred name use and one resident would be happier if staff shut their bedroom door again after entering when they weren’t there. Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 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. Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 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 Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 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 the following standard(s): Not judged on this occasion. EVIDENCE: Not assessed during this inspection. Please see previous inspection reports. Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 10 The staff have a good understanding of the health and personal care needs of residents, this could be documented more clearly in care plans. Residents’ privacy and dignity are generally well promoted, though staff could further improve the way in which they address residents. EVIDENCE: Three care files were looked at. These contained good assessments with excellent Personal Activity records. There were appropriate Manual Handling risk assessments and regular monthly reviews. Visits from external health care professionals were good and the senior carer said that the Home had a good relationship with the local surgery commenting that ‘they were brilliant’ in supporting the Home. In some plans identified issues were well recorded with detailed action plans but other issues, which were clear when talking to the residents were not clearly outlined in the notes such as anxiety (which was brief), toileting or why someone was being nursed in bed. One plan stated that a resident was ‘feeling poorly and nearly fell’. The notes did not follow this up. There were no social history records or evidence of resident involvement in plans or reviews. All residents said that they were very happy with the care and the inspector observed staff looking after residents in a knowledgeable and Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 Page 10 caring way, with insight to maintaining independence and choice, such as bathing in private. One resident said that they did not know that they could bathe in private so staff said that they would ensure that this was clear pending risk assessment. Residents confirmed that staff knocked on doors before entering, however 5 did comment that they were not always addressed by their preferred names, which they sometimes felt was disrespectful. One resident would prefer staff to shut their bedroom door again after entering when they were not in their room. The inspector noticed that staff maintained residents’ privacy when giving any sensitive assistance. Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 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 the following standard(s): Not judged on this occasion. EVIDENCE: Not assessed during this inspection. Please see previous inspection report. Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 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 the following standard(s): 17, 18 Residents are protected from harm or abuse as sound procedures and practices are in place, other than in one area of decision-making. EVIDENCE: The Home has a comprehensive Protection of Vulnerable Adults policy, which staff sign to say that they have read. This includes the correct procedure for informing other agencies and documentation and whistle blowing. The Home has the Alerters’ Guide. Training files were looked at and the majority of staff have attended POVA training and had completed follow up competency questionnaires, including institutional abuse topics and subtle abuse. Staff were aware of POVA issues and restraint. Those residents using bed rails had risk assessments in their care files but these were signed by staff rather than a multidisciplinary decision involving the resident and representative as appropriate or records as to why this may not be possible, i.e. mental capacity. Polices and the Statement of Purpose clearly sets out residents’ rights although most of the residents were not aware of these such as that they can go out. Staff confirmed that there were no restrictions unless suggested by risk assessments and that they would ensure that residents were regularly reminded of their rights. Voting is done at the local polling station or by postal vote. Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 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 the following standard(s): 24, 26 The standard of the environment is high, providing residents with an attractive, safe and clean place to live. EVIDENCE: The inspector looked at the majority of residents’ rooms. All were decorated to a good standard, many with new bedroom furniture and personalised as residents wished. Each room has a smart new name-plate. One resident kindly showed the inspector their room, which they were pleased with and showed how they had been able to put things wherever they liked. All residents have been offered keys to lockable storage in their rooms and most rooms have an appropriate locking devise, to which residents may have a key. The Home was clean throughout and a new commode use policy has been devised and a copy given to all staff. The Home has plans to invest in a sluice, rather than using the large sink in the clean laundry area. Residents said that laundry was well looked after by the Home and one resident said that they were also able to give theirs to family members to do if they wished. Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not judged on this occasion. EVIDENCE: Not assessed during this inspection. Please see previous inspection report. Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 EVIDENCE: CSCI is awaiting an application for a new Registered Manager for the Home since the current Registered Manager re-located within the company. They now visit the Home weekly. The Registered Provider also sends Regulation 26 monthly audits to CSCI. The Home has a Quality Assurance system and this is currently underway with 5 more residents’ questionnaires to do. These can be returned anonymously if residents wish and the form notes if staff have assisted residents. Topics include, care, staff, meals and activities. This will be collated and a summary sent to CSCI as per the National Minimum Standards. It is suggested that a questionnaire also be sent separately to relatives, especially if residents need assistance to fill them in and also to relevant external health care professionals. Records of residents’ monies were looked act. Three pouches were checked and all were correct with clear itemised Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 Page 16 records and receipts. The Home is not an appointee for any resident who have private arrangements and an invoicing system. Standard 38 was not fully assessed but all appropriate fire doors now have automatic door closers fitted. Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X 3 X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 Page 18 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. 1 Refer to Standard OP7 Good Practice Recommendations It is recommended that records clearly state action plans for all residents’ needs and that files include social histories, especially for those with dementia or communication problems. It is recommended that staff address all residents by their preferred form of address and that this is clearly documented. This is carried over from the previous inspection. It is recommended that any decisions relating to the use of bed rails are clearly discussed and documented with the multidisciplinary team and include the resident/representative as appropriate. 2 OP10 3 OP18 Kenwyn, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Exeter 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, Crediton DS0000063516.V279997.R01.S.doc Version 5.1 Page 20 - 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!