Inspection on 22/03/06 for Kestrel House

This inspection was carried out on 22nd March 2006.

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 5 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 13/12/05

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 22 March 2006 13:00 nd Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 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.V284217.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 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.V284217.R01.S.doc Version 5.1 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.V284217.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2005 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.V284217.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is the result of an unannounced inspection undertaken in midMarch 2006. The inspector spoke with service users, staff, manager and a visitor to the home. The inspector observed the interaction between staff and service users, read documents pertaining to the running of the care home and plans relating to the care provided to service users. The inspector would like to thank everyone 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 home needs to ensure service users receive their medication as prescribed. The service will have to undertake a training needs analysis and develop a plan for the staff team. Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 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.V284217.R01.S.doc Version 5.1 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.V284217.R01.S.doc Version 5.1 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): EVIDENCE: There have been no admissions since the last inspection, these standards were not tested. Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 The service provides excellent details on how staff are to provide care for service users. EVIDENCE: The inspector read a service users care file. The care plan was excellent and covered every aspect of care highlighted in the referral assessment. The inspector was very impressed with the level of detail each objective had to direct staff provide the appropriate support needed. There was good evidence that the service user had been part to the creation of the plan of care as she had signed agreement to each objective. The review of the care plan was also in place. The inspector read a risk assessment around the nutritional needs of the service user and a risk assessment that arose out of the mental health needs of the service user; it addressed and graded the degree of risk for suicide, selfneglect, vulnerability and aggression. The inspector was satisfied that the service had undertaken an extensive assessment and had put in place strategies to address these. These include contingency plans should concerns arise. Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 Page 10 There was evidence that discussion takes place in the form of service user meetings and service user discussion groups. However on reading the minutes of these there was little evidence to support consistent consultation. There was evidence that some meetings were used to reinforce house rules. Whilst the inspector accepts this may be a legitimate agenda it should not be the focus of the meetings. Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 Page 11 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): 11,12,13, 17 The staff team at Kestrel House support service users personal development and actively work with them to improve their outcomes. EVIDENCE: The service users in Kestrel House have support for staff to develop social and independent living skills. Care plans accurately reflect how staff sensitively supports a service user to regain independent living skills such as keeping her bedroom tidy. Four service users are attending computer courses and two are undertaking training 3 days a week tie undertake “odd jobs” safely. Two service users have been interviewed and accepted for places on courses on assertiveness training and career development. One service user has found himself an appropriate job. The service has a cook who comes in to prepare a full evening meal. Service users are offer a choice at this meal. One service users told the inspector “the food is very good”. Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Management within the home respond promptly and appropriately to any service user health changes and advocate on behalf of the service users to ensure they get prompt treatment. EVIDENCE: The inspector was impressed with observational skills of staff and the promptness with which appropriate health support is sought. On the day of the inspection the manager was rostered to be a day off but he had visited the home to support staff seek prompt response form the mental health team to concerns staff had just observed in the service user. The result was that with the course of a day symptoms were accurately noted, reported and intervention sought for the service user. Such a prompt response was very reassuring. There was also good clear evidence of staff spending time with a service user assessing her mental health and providing a time for the service user to talk with staff about her emotional health. Service users medication is held securely in a locked cabinet. The inspector undertook a random check of the medication. On one service user’s Medication Administration Record there was medication that had not been signed for. Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 Page 13 Therefore the home is unable to provide evidence that the service user had been given her medication as prescribed. Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 Page 14 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 Service users know how and who to complain to. EVIDENCE: The home has a complaints procedure to guide service users how to raise concerns. There have been no complaints recorded. One service user told the inspector that if he had any complaints to make he would speak directly to the manager. The service has an adult protection procedure in place. There have been no adult protection issues in the service. Staff have recently completed training in Adult Protection. Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 Page 15 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 The service users have care provided in a home that is clean and comfortable. EVIDENCE: The provider has put window dressing in the bathrooms as required. The home remains clean and hygienic throughout. The sofas in the ground floor lounge are worn and the fabric covering has cracked. The manager stated that the budget has been planned to accommodate the replacement of this worn furniture. Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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): 32, 34, 35 The service will have to address the training needs and development of the staff team. EVIDENCE: The inspector observed the interaction between staff and service users and noted how positive it was. In general staff have a relax, calm approach and were seen interacting with service users either over a game of pool, dominoes or working with service users on the home’s computer. Of the twelve care staff in post 2 hold NVQ 3 awards; and 3 hold NVQ 2 awards. This falls below the minimum 50 so the home will have to make plans to ensure further staff hold an award. The inspector checked a recently appointed member of staff’s file. The file held photographic identification, a completed application with detailed employment history, two satisfactory references and a CRB disclosure. The disclosure was also satisfactory although it had been undertaken 11 months before appointment. The manager stated his umberella body had advised him that this was satisfactory. The Manager has agreed that he will undertake a CRB disclosure before appointing staff. The home does not have a training and development plan and the manager stated he was undertaking a training needs analysis of the staff team from which to develop the plan. Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 Page 17 Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 Page 18 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, 39 The service is competently managed. EVIDENCE: The manager of the service hold his Registered Managers Award and is dual qualified in mental health and general nursing. He has extensive experience in managing services and is skilled and knowledgeable in working with people with mental health conditions. The manager has demonstrated his competence in managing the service. The service addresses statutory requirement in a timely fashion. The service has introduced service user feedback surveys these need to be form part of a quality assurance system and ultimately a development plan for the home. Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 2 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 2 X X X X Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 Page 20 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 YA8 Regulation 12 Timescale for action The registered manager will have 01/06/06 to review and implement new ways of consulting service users and evidence how their feedback contributes to the running or development of the service. The registered manager must 01/05/06 ensure that all service users receive their medication as prescribed. The registered manager must 01/05/06 provide plans of how to increase the percentage of NVQ staff in post. The registered manager must 01/05/06 provide the Commission with the staff teams training and development plan. The registered manager must 01/06/06 implement an effective quality assurance monitoring system. Requirement 2 YA20 13 3 YA32 18 4 YA35 18 5 YA39 24 Kestrel House DS0000007223.V284217.R01.S.doc Version 5.1 Page 21 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.V284217.R01.S.doc Version 5.1 Page 22 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.V284217.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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