Inspection on 31/05/05 for Kestrel House, St Anne`s Opportunity Centre,

This inspection was carried out on 31st May 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

Kestrel House, St Anne`s... 09/05/07

Kestrel House, St Anne`s... 13/12/05

Kestrel House, St Anne`s... 22/12/04

Kestrel House, St Anne`s... 29/04/04

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

CARE HOME ADULTS 18-65 KESTREL HOUSE St Annes Opportunity Centre 84 Hambridge Road Newbury RG14 5TA Lead Inspector Tracy McGuire-Brown Unannounced 31 May 2005, 10:00 am 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kestrel House Address St Annes Opportunity Centre, 84 Hambridge Road, Newbury, Berks, RG14 5TA 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) 01635 40862 St Annes Opportunity Centre Ltd Mrs Samantha Chengun Care Home (CRH) 3 Category(ies) of Learning disability (LD) registration, with number of places KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22 December 2004 Brief Description of the Service: Kestrel House is a small residential home located close to the local town and all amenities. The home is registered for 3 service users aged 18 - 65 years who learning disabilities. The home offers structured care to enable service users to develop more independent life skills at their own pace and within their own abilities. The home is well equipped throughout and has a large secluded garden which is well utilised. KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection conducted over 6 hours. The Inspector was shown around the home by the residents, including bedrooms and bathrooms. Residents care records and additional information was looked at. The Inspector spent some time with the 3 service users and the Manager of the home. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 7 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 standard(s) 2 The home gains detailed assessment information about each service user prior to admission. There is a satisfactory admission process in place. EVIDENCE: There have been no new admissions to the home since the previous inspection. The home has a comprehensive referrals and admissions policies. Service user files contain historical assessments which include detailed care management and healthcare assessments. KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 8 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 standard(s) 6, 7 and 9 Service users all have individual care plans. These are regularly reviewed. Service users sign their care plans. Service users are consulted and involved in making decisions about all aspects of their likes. Service users have risk assessments in place to support care plans. EVIDENCE: Detailed care plans are in place for each individual service user. Care plans are monitored and reviewed with service users on a regular basis. Records seen demonstrate that service users sign their care plans and reviews. Service users spoken to had clear knowledge of their care plans. Records were seen for service users and meeting records demonstrate that service users are consulted about all aspects of life and are involved in decision making. Service users each take a turn at “chairing” the service user meeting for 20 minutes each. Detailed risk assessments are in place to ensure the safety of service users and these are reviewed. On the day of inspection several risk assessments were in the process of being reviewed and updated. KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 9 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 standard(s) 12, 13, 14, 15, 16 and 17 Service users have a range of appropriate education and leisure activities which encourage personal development. Service users all use the local community. Service users are supported to maintain and develop appropriate relationships. Service users rights and responsibilities are respected. Service users have a choice of varied and well balanced meals. EVIDENCE: Service users all have individual Personal Programmes which detail varied day occupations. These include, attendance at the local college, Mencap groups, work experience, music and art therapy. Service users informed the Inspector that they do activities such as, “computers, cookery, pottery and drama” at college. KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 10 Service users informed the Inspector that they, “go out for pub meals, go to the local supermarket and shops, use local GP, dentist and other healthcare services.” Service users make good use of the local community. Daily diaries and personal diaries indicate use of the community including leisure and education purposes. Service users chair regular meetings and these are used to record and discuss a variety of issues include the running of the home. Rotas are drawn up to agree and share tasks. Daily diaries and individual files indicate that service users are supported to maintain and develop relationships with family and friends. Service users were seen spending time together or alone in their rooms if they choose, privacy is respected and there is a personalised notice on each bedroom door to knock. There are currently chain style locks fitted to bedroom doors and the organisation is reviewing the safety of this. Menus were seen and these are individual and group. Menus are varied, well balanced and reflect personal and group choice. Service users informed the Inspector they enjoy regular pub lunches and takeaways also. KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 11 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 standard(s) 18, 19 and 20 The physical and emotional well being of service users is carefully considered and well met. Medication processes are safe. EVIDENCE: Each individual has a ‘health care profile’ and ‘medications profile’ which is signed by the service user. Care plans detail personal support preferences. Comprehensive assessment in respect of audiology, psychiatry were seen. An audit of healthcare is reported at each service users’ review. Healthcare appointments are all recorded. The C.S.C.I. Pharmacist Inspector visited one of the organisation’s homes to review the standard medication procedures which were found to be satisfactory. Staff are trained in administration of medication. All medication is stored securely. KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 12 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 standard(s) 22 and 23 The home has satisfactory complaints procedures and protects service users from abuse. EVIDENCE: The home has a detailed complaints policy in place and an additional leaflet about how to complain on each service user’s file. Service users all informed the Inspector of how that would complain if they needed to. The home logs all complaints and details relevant actions. There are no complaints since the previous inspection. The home has detailed policies in respect of the protection and recognition of the Protection of Vulnerable Adults. Staff have attended Vulnerable Adults training. KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 13 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 standard(s) 24, 25, 26, 27, 28, 29 and 30 The home has a homely feel and is safe and comfortable. Service users have single bedrooms and suitable bathroom facilities. The home is clean, tidy and hygienic and generally well maintained. EVIDENCE: The service users showed the Inspector around the home. The home was well, furnished and equipped and service users rooms were all personalised. Service users are clearly proud of their rooms. There is a large bathroom with WC on the first floor and an outside toile downstairs. The home has plenty of communal space and a very large secluded garden in which service users have a patch of ground each to grow vegetables. There is a separate laundry area accessed via the kitchen. The home is clean and tidy. KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 and 36 Recruitment records are detailed and recruitment processes are in place to protect service users. Training is ongoing for staff to ensure competence. Staff are supported and supervised. EVIDENCE: Samples of recruitment records are located in the organisations main office which is also located in the home. Records indicate that application forms and relevant checks including CRB and 2 references are undertaken. The Inspector and Manager discussed the fact of POVA and CRB checks must be in place prior to any appointment being made. Training profiles were seen for staff and training is regular and ongoing. YOPPS and Induction and Foundation training is undertaken. Certificates were seen for e.g. Fire, First Aid, Food Hygiene, Vulnerable Adults, Safe working Practices and NVQ’s. Sample supervision records were seen. Staff have regular supervision and supervisors have undertaken training. This was a previous recommendation. KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 41 and 42 Service users rights and interests are safeguarded by record keeping policies and procedures. Health and Safety is promoted. EVIDENCE: A varied sample of policies, procedures and records were examined. Records in the home are well organised, detailed, up to date and reviewed on a regular basis. This is an improvement since the previous inspection. Health and safety policies, procedures and risk assessments are in place. COSHH details are reviewed. Regular Health and Safety checks are made in the home and records were seen for fridge freezer and water temperatures, fire drills and testing, gas and electrical testing, and these are up to date. The home records accidents, incidents, hazards and dangers and action taken in separate books. Risk assessments are in place in respect of water temperatures exceeding KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 16 43degrees and assessment of service users capabilities. This issue needs continued monitoring and reviewing to ensure safety. KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 17 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 x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 KESTREL HOUSE Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x 3 3 x H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 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. 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. Refer to Standard 16 42 Good Practice Recommendations The home reviews and informs the C.S.C.I in writing the arrangements for chains on Service bedroom doors. The home continues to review, monitor and recrds recrds in respect of water temperatures including capability assessments and risk assessments. KESTREL HOUSE H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection 1015 Arlington Business Park Theale Berks RG7 4SA 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 H52-H01-S11175-Kestrel House-V230058310505-Stage 4.doc Version 1.30 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. 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