Inspection on 15/09/05 for Kevlin

This inspection was carried out on 15th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Kevlin 09/05/07

Kevlin 10/01/06

Kevlin 14/01/05

Kevlin 02/08/04

Kevlin 19/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Kevlin 66/68 Norwich Road North Walsham Norfolk NR28 0DX Lead Inspector Jenny Rose Unannounced Inspection 15th September 2005 11.00a 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 Kevlin DS0000027292.V250692.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 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. Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kevlin Address 66/68 Norwich Road North Walsham Norfolk NR28 0DX 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) 01692 402355 NO FAX # Mrs Diana Tripp Mr Derek Tripp Care Home 14 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (14) of places Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th January 2005 Brief Description of the Service: Kevlin is a care home providing personal care and accommodation for 14 older people. Mr Derek and Mrs Diane Tripp own the home. The home is located on the outskirts of North Walsham and is close to local shops, pubs and local amenities. The home is a three-storey building, with service user accommodation located on the ground and first floors. Communal areas are located on the ground floor and service users’ bedrooms are on the ground and first floors. A stair climber provides assisted passage to the first floor. There are twelve single bedrooms and one shared bedroom. There is easy access to the rear gardens from the main lounge and dining room. On-road parking is available outside of the home. Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection taking place over 5 hours on a weekday. The Providers, Mr and Mrs Tripp were in attendance throughout. There were 14 service users in residence. Preparation had taken place in the CSCI office beforehand and many records were seen. Comment cards were left at the home for completion by service users and visitors to the home. Two members of staff were spoken to and three service users privately. What the service does well: What has improved since the last inspection? What they could do better: * The home works hard to obtain two written references for new staff and this should be ongoing. * It would be best practice to administer medication via individual ‘pots’ to service users. Kevlin DS0000027292.V250692.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. Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 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 Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 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): 3 The home has a clear pre-assessment procedure, which ensures as far as possible that the home can meet the service user’s needs. EVIDENCE: The home has a clear pre-assessment procedure which was confirmed by records, talking to staff and service users. The home has developed its own comprehensive pre-assessment checklist for assessing prospective service users’ needs and ascertaining whether the home can meet those needs. Prospective service users and/or their relatives come to look around the home, if appropriate. A senior member of staff confirmed that it is usual practice to visit the prospective service user at home or hospital, as she had done for the most recent service user in the home. She had had meetings with Social Services, hospital staff, the family and then with the service user privately. He too confirmed the procedure. This assessment then forms the basis of the care plans. Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 9 Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 10 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): 7,8,9 The home is aware of the changing needs of the service users and these changes are appropriately recorded in the care plans and are reviewed with the service user and/or their relatives if appropriate. EVIDENCE: Three care plans with risk assessments were seen. The home give high priority to continuously improving their care plan recording to take account of the service users’ changing needs. The care plans contain good quality information to assist staff in meeting service users’ needs. The care plans seen included family history, significant events, service users’ aspirations, as well as personal care needs, medical assessments and advice from health care professionals for physical and mental health needs, where appropriate. Service users’ wishes for their funeral arrangements were recorded, where appropriate, and there were appropriate risk assessments. Two service users spoken to said the “the girls are very kind” and take notice of their wishes. The home operates a keyworker system, which further ensures that individual preferences of service users are attended to. These Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 11 two service users also commented that the food was good and that a special diet was provided for one of them Risk assessments contain good information and involve the service user’s family if appropriate. These and the care plans were regularly reviewed with the service user and/or their relatives. A risk assessment signed by a member of the service user’s family was seen. This is seen to be good practice. It was evident from the care plans and talking with staff that advice from other healthcare professionals was sought when necessary. Not all the elements of the medication were examined on this occasion, but the medication round was observed from the MDS system and there is a recommendation regarding this. All staff administering medication have undergone training, as seen from the staff files and there are policies and procedures for the safe administration of medicines. The Deputy Manager orders and checks the medication in. On the day of the inspection there were new MAR sheets. Any returns of medication would be recorded on the MAR sheets. There are no service users requiring Controlled Drugs, although there are facilities for their safe keeping. There was one service user self medicating for a prn medication and the Mrs Tripp confirmed that there was a risk assessment in place for this. Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 12 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): 12,13,14 The home supports service users in exercising personal choice in daily routines and activities in and outside the home, which enhances the service users’ quality of life. EVIDENCE: There was evidence from talking with service users and staff and from preferences recorded in care plans that the home makes efforts to ensure that the routines of daily living suit individual service users. There was evidence that the home has a designated person to provide activities for service users on a weekly basis, should they wish to partake in them and from the visitors’ book and speaking with service users, it was clear that residents receive visitors at any reasonable time. There were regular outings to a nearby Garden Centre where residents could do shopping and have a drink and a snack if they wished. Two Ministers visit on a regular basis. Service users are supported in exercising personal autonomy and choice and evidence of this was provided by observation of a service user arriving home in a taxi, having been into the town, which he does regularly. Arrangements had also been made for married service users to have a private sitting area together. Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 13 One service user spoken to said “I enjoy a good laugh and joke with the girls” and he commented favourably on the arrangements for the laundry in the home, which he said was “spotless”. He also confirmed that the “meals are good”. Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 14 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): 16,18 There is a clear complaints procedure and any complaints are appropriately acted upon, ensuring that service users and their relatives and friends are confident that complaints will be taken seriously. The home places emphasis on staff training in issues surrounding the Protection of Vulnerable Adults, thus ensuring, as far as possible, that service users are protected from abuse. EVIDENCE: There is a clear complaints procedure and there has been one complaint received in the CSCI office concerning a visiting Healthcare Professional, but this is being appropriately dealt with and a comprehensive risk assessment on premises has recently taken place with the appropriate professional advice. Service users spoken to were clear that they were aware of the complaints procedure and would feel able to speak to the management if they had any reason to complain. The home has not reneged on its priority given to the issues of adult protection. There was evidence, both from files and from speaking with staff that they are well trained with regard to the Protection of Vulnerable Adults and they gave a good account of their knowledge during the inspection. The most recent prospective member of staff, who was observing and shadowing more experienced members of staff, was also well versed in these issues. She Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 15 was aware of the home’s Whistle Blowing Policy and knew what action to take, should it ever be necessary. Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 16 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): 19,20,26 The environment provides a safe, comfortable, domestic home for service users. EVIDENCE: The Conservatory is a fairly recent addition to the home, which provides a pleasant light, dining room overlooking the garden with a mature eucalyptus tree giving shade in summer. Service users have access to a secure garden, if they choose. The conservatory provides an extension to the lounge area and an area affording privacy for service users’ visitors if necessary, at different times of the day. The Conservatory also provides a ‘bar’ area for those service users wishing for alcoholic or soft drinks. Service users have access to a communal room off the kitchen, which is also used by staff, if they wish. Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 17 There is an ongoing maintenance programme and a revised, comprehensive risk assessment of premises has recently been undertaken with professional advice. All areas of the home seen were clean and hygienic. This was commented on favourably by one of the service users. Staff undergo a course in Infection Control. Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 18 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): 29,30 Although the home makes every effort to obtain two references for prospective members of staff, two written references would further ensure the protection of service users. The home gives high priority to training which ensures that as far as possible service users changing needs are recognised and met EVIDENCE: The home makes every effort to obtain two written references for staff and the format used by the home requesting a reference was seen, together with the application form for prospective staff, which sought appropriate information. Although two references had been obtained for new members of staff, it was occasionally only by telephone, as referees often did not reply in writing. Therefore there is a recommendation regarding this. Two members of staff were spoken to, both of whom were enthusiastic about their jobs and said individually that the considered the home to be a “happy one” with a good staff team. Staff development files were seen which give evidence of the home’s commitment to training, which was confirmed by both members of staff spoken to. One experienced member of staff, with an NVQlll qualification, spoke of a recent course she had undertaken in Dementia, which she found to be useful in renewing her previous knowledge. She said that issues of Adult Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 19 Abuse are discussed all the time with new staff and there are regular staff and senior meetings, and meetings can be called if necessary. She also confirmed that staff underwent regular supervision. The most recent prospective member of staff, undergoing a probationary period, was observing and shadowing more experienced staff and gave a good account of such issues as privacy and dignity for service users, treating service users as individuals and also gave evidence of her induction training, including issues such as adult abuse. They both confirmed that there was a good staff team and they felt able to approach the management and felt well supported by them. Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 20 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): 33,38 Service users’ views are sought to ensure that as far as possible the home is run in the service users’ interests and that the policies and procedures safeguard their health, safety and welfare. EVIDENCE: Service users views are sought annually and this was seen during the inspection. The information is used to improve the service. The Accident Book was seen and appropriate action seen to be taken if necessary. There had been no admissions to hospital as a result of accidents. Premises risk assessments were seen and the most recent risk assessment had been carried out with the help of professional advice, as mentioned elsewhere in this report. Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 21 Records were also seen for fire alarm testing, and the maintenance of the stair lift. A letter to service users’ relatives regarding the use of cleaning materials by service users was seen to be sent on 21 August 2005. Kevlin DS0000027292.V250692.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 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 3 3 X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 3 Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? No 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 19 (1c) Requirement The registered persons shall not employ a person to work at the care home unless they are satisfied on reasonable grounds as to the authenticity of the references referred to in paragraph 5 of Schedule 2 in respect of that person. Timescale for action 05/10/05 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 OP9 Good Practice Recommendations It is recommended that it would be best practice to administer medication into individual pots before handing DS0000027292.V250692.R01.S.doc Version 5.0 Page 24 Kevlin to service users, rather than on to a table. Kevlin DS0000027292.V250692.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Kevlin DS0000027292.V250692.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. 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