Inspection on 13/12/05 for Kestrel House

This inspection was carried out on 13th December 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kestrel House 20/03/07

Kestrel House 22/03/06

Kestrel House 09/12/04

Kestrel House 21/06/04

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

CARE HOME ADULTS 18-65 Kestrel House 75 Harold Road Leytonstone London E11 4QX Lead Inspector Zita McCarry Unannounced Inspection 13th December 2005 1:00 Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kestrel House Address 75 Harold Road Leytonstone London E11 4QX 020 8556 4037 0208 558 2761 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) Shanti Healthcare Limited Mr Neraindas Nunkoo Mr Neraindas Nunkoo Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th December 2004 Brief Description of the Service: Kestrel House is a care home, which offers personal care and support to younger adults who have mental health support needs. Kestrel House is a large semi-detached house situated in a quiet residential area of Leytonstone. It is privately owned and operated and the registered manager is one of the registered providers. The home is close to local shops and other community facilities and there are good links to public transport. Whilst there is one double room only one service user occupies it. All but one bedroom has en-suite facilities and are situated on the ground and first floor. Communal space and appropriate bathroom and toilet facilities are available. There is a passenger lift to the first floor. There is a large garden available for the use of service users. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report on the findings of a three-hour inspection one afternoon in mid December. The manager was not on duty. As part of the inspection the inspector spoke with service users and staff, reviewed documents pertaining to the running of the home and care files describing how the home meets the needs of service users. The inspector would like to thank service users and staff for their assistance in the inspection process. What the service does well: What has improved since the last inspection? What they could do better: The service must improve upon its recruitment processes and the Commission is considering enforcement action to ensure satisfactory checks are undertaken before employment is commenced. The service will have to notify the Commission of events that affect the wellbeing of service users. Whilst risk assessments are in place they do not provide adequate information on how to manage the identified risk. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 6 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. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 The staff at Kestrel House undertake detailed assessments and monitoring, which ensures they can meet prospective service users needs and keep them safe before they actually come to live in the home. EVIDENCE: The inspector read the home Statement of Purpose and Service Users Guide, both these documents have been developed to meet the criteria as detailed in the regulations. The Deputy Manager explained that the service would be undertaking more work in clarifying the criteria for admission and format in which the Service Users guide is presented. The inspector randomly selected a file of a recently admitted service user. There was considerable pre-admission assessments on file including a care programme approach and the home’s own pre-admission assessment. There was a long period of time between referral and admission. However there was good evidence that the home had used the time to support the service user with frequent visits and overnight stays prior to the service user moving in. The staff made good observational recording on the daily records which were concise and noted how the service user was finding life at the home. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 9 The inspector was satisfied that the home undertook all the necessary checks and monitoring to ensure it could meet the needs of the prospective service user. The inspector saw the home’s statement of terms and conditions which was signed by both the homes manager and service user. Additionally, the home also has a set of house rules which is signed by the prospective service user, this document addresses anti-social behaviour, drugs and alcohol and behaviour in the local community. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Whilst the care planning in the home has improved further work needs to be undertaken to ensure comprehensive risk management strategies are in place. EVIDENCE: The care planning in the home has been revised and improved the care plans. The new format is less complicated the inspector read two service users care plans and their corresponding risk assessments. The inspector read the nutritional assessments on file for both of the service users. The care plans seen were signed and agreed by the service user. Most aspects of the care plans were detailed and offered staff clear guidelines in how to meet a particular area of need. However on both plans checked the objectives relating to social/occupational activities was particularly vague. Each care plan is underpinned by a risk assessment with each risk graded in terms of the level of risk presented. One assessment had no presenting high risks. However on the other assessment where a high risk was identified the strategies for managing the risk as detailed on the care plan were inadequate. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 11 From discussion with the deputy manager the inspector was satisfied that in practice staff were taking precautions, however these need to be recorded particularly when staff consider they my have to implement strategies that infringe on service users rights. There was evidence that Kestrel House offers service users the opportunity to get involved in the running of the home The home holds discussion groups and service users meetings. Whilst the content of these were good and provided evidence that the service was responsive to service users issues they have not taken place regularly. For example the last recorded discussion group took place 6 months earlier. Service users files are held securely in a locked office. Staff demonstrated a good understanding of how to handle information appropriately. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14, 16, 17 The service fails to adequately support service users take part in appropriate leisure, social or fulfilling activities. EVIDENCE: As recorded earlier in this report the home does not plan effectively for individualised social or leisure activities. The service holds a central plan for group activities offered to service users. Neither care plans seen nor the activity schedule provided evidence that the home was actively promoting daily living skills. The last recorded supervised cooking session was also 6 months earlier. Service users hold keys to their rooms and staff were observed to ask service users permission to gain entry to their private accommodation. The home offers service users a choice of communal living space to choose from so they can decide whether to be alone or in the company of others. The home has a 4 week menu plan but also records what service users have actually chosen to eat. One service user told the inspector that the food was “OK” but confirmed he did not cook himself. Both the menu and record of foods provided appear nutritious. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 13 There was evidence that the staff in the home support service users links with their families both within the home and at visiting centres appropriately. Staff and a service user confirmed that visitors are be received in the homes visiting room, lounges or the privacy of bedrooms. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 Service users have access to primary health care and staff within the home ensure service users have health is maintained. EVIDENCE: Staff and a service user confirmed that personal care is delivered with due regard to privacy. Service users have designated keyworkers to offer continuity of care. In addition to the staff team community psychiatric nurses who monitor and review the mental health of service users support service users. Service users are registered with a local GP practice. Service users care plans reflected how staff were promoting service users health by appropriate diet and monitoring. The inspector checked the accident records and noted there have been no recorded accidents in the home in the past year. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The service has in place the procedure to respond to concerns and complaints and action to take in response to any allegations of abuse. EVIDENCE: The service has a comprehensive and accessible complaints procedure to guide staff and advise service users how to complaint. There was one complaint recorded and this was responded to appropriately. There have been no adult protection concerns recorded. The service has a procedure to guide staff in how to respond appropriately to any suspicions or actual abuse. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28 The service is clean and comfortable however attention needs to be given to bathrooms, which through age appear grubby and worn. EVIDENCE: Kestrel is a large property in a residential area that is close to local amenities. The service is in keeping with the other houses in the road and nothing sets it apart. A camera is used at the front door only for security reasons. The inspector toured the home and saw two service users bedrooms. The home does not provide care for service users with a physical disability. The building is suited to the aims and objectives of the service. Two service users showed the inspector their rooms, which were suitably furnished, and although they lacked personal items on the walls both service users said they liked their rooms and were comfortable in them. Service users hold their own room keys. There are a sufficient number of bathrooms and toilets for the number of service users. The provider has rectified the previous problem with the hot water supply. All the bathrooms and toilets had appropriate locking mechanisms however the bathrooms are in needs of a refurbishment because Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 17 of the age the tiles and bath surfaces appear grubby and unclean. Window coverings must be put in place to ensure privacy in bathroom and toilets. The home has a large through lounge and dining area on the ground floor. On the first floor there is a smaller lounge, which has been vastly improved following a redecoration and window covering. Additionally, there is a a third lounge for receiving visitors or holding meetings. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 The service fails to adhere to a robust recruitment process, which undermines the protection of vulnerable adults. EVIDENCE: Staff have a job description and from discussion it was evident that they understood their roles and responsibilities. Staff were observed by the inspector to be interacting in a supportive and respectful manner with service users. The inspector read written comments service users made about Kestrel House and they were particularly positive about the support they receive from staff. The home has two care staff and a shift leader on each shift with additional ancillary support. The inspector could see find no evidence that staffing levels were insufficient. However it was noted that the staff rota has no overlap of shifts to accommodate a comprehensive handover of information between shifts and this will need to be rectified. To test the robustness of the home’s recruitment processes the inspector reviewed the file of a recently appointed member of staff. The file failed to provide evidence that the service had taken sufficient pre-employment checks to ensure the safety of service users. There was no evidence of a PoVA first check or CRB disclosure application. There was a disclosure almost three years old when the applicant worked in childcare so no checks have been undertaken against the vulnerable adults list. There was no photographic identification or Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 19 record of interview. Only one of the references was as recorded on the application form with no reason recorded why another person had been approached to act as a referee. The inspector left a notice requiring the service to act immediately to ensure only staff with complete and satisfactory checks could work in the home. This failure to safely recruit staff was evident at a previous inspection and because of this the Commission is now considering enforcement action to ensure compliance and the protection of vulnerable adults. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 40, 42 Staff take adequate steps to ensure service user health and safety. EVIDENCE: The home has clear guidelines and policies in place to guide staff on duty. The procedures are accessible to staff in the managers office. It was noted in the inspection of fire records that the home had an incident a few months earlier when the fire alarm was activated, and the fire brigade attended it was discovered that in a service users bedroom “black ash and water” was found. Whilst staff took the correct immediate action in calling the emergency services the home did not, as required, by regulation inform the Commission of this serious event. The inspector read a variety of records to demonstrate that staff take steps to ensure their own and service users health and safety. The home undertakes weekly fire alarm checks, the fire alarm and emergency lighting system has been serviced, the home holds a current gas safety certificate. Staff also monitor fridge and freezer temperatures to ensure the safe storage of food. Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 21 Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 22 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 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 2 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 2 3 X 3 LIFESTYLES Standard No Score 11 X 12 2 13 X 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X 2 1 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kestrel House Score 3 3 X x Standard No 37 38 39 40 41 42 43 Score 2 X X 3 3 3 x DS0000007223.V273251.R01.S.doc Version 5.0 Page 23 yes 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 YA6 Regulation 15 Requirement The registered person must ensure that the care plans sufficiently describe how the service will meet identified areas of need. (unmet from previous inspection) The registered person must ensure all risks identified have an adequate strategy in place for their management. (unmet from previous inspection) The registered person must ensure service users are consulted at regular intervals and evidence of this must be provided. (unmet from previous inspection) The registered person must ensure that individual service user are supported to take part in fulfilling activities. The registered provider must ensure bathrooms and toilets have window coverings to ensure privacy . The registered person will have to ensure that the staff rota accommodates a comprehensive handover of information between shifts. DS0000007223.V273251.R01.S.doc Timescale for action 15/02/06 2 YA9 13 15/02/06 3 YA8 16 15/02/06 4 YA14YA12 12&16 15/03/06 5 YA27 12 15/03/06 6 YA33 18 15/03/06 Kestrel House Version 5.0 Page 24 7 YA37 37 The registered manager must ensure the Commission is notified without delay of events as detailed in regulation 37. 15/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Kestrel House DS0000007223.V273251.R01.S.doc Version 5.0 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!