Inspection on 09/05/07 for Kevlin

This inspection was carried out on 9th May 2007.

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

Kevlin 10/01/06

Kevlin 15/09/05

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 Hilda Stephenson Unannounced Inspection 9th May 2007 10:00 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.V339408.R01.S.doc Version 5.2 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.V339408.R01.S.doc Version 5.2 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 Mrs Diana Tripp Mr Derek Tripp Not applicable 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.V339408.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 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 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.V339408.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit to Kevlin took place during the day on the 9th May 2007 as an unannounced inspection to check the key standards. These standards were inspected, although not all the elements may have been examined. The evidence gathered to publish this report was obtained by speaking to five of the fourteen residents, two of the proprietors, two staff and the deputy manager. Time was taken by checking through care records, medication records, policies and procedures, comments and information received prior to this visit. The Commission also looks at other information it has received since the previous inspection which may include complaints about the service, evidence of good care practice as well as any views about the service held by other professionals such as G.P.’s. The home was found to be clean, tidy and free from odour. The majority of residents were either in their own bedrooms or sitting in the lounge areas. What the service does well: Kevlin is registered to care for fourteen residents. They also care for one resident who visits for the day. A clear and concise assessment of care needs is undertaken prior to residents moving into the home. The home has a small loyal staff team to care for the current fourteen residents and is managed by both proprietors who have worked and owned the home for many years. Staff receives varied training to assist them to care for the residents to enable them to live within a safe and homely environment. The residents are treated with respect by the staff. Some residents stated that they felt ‘like part of the family’. The residents confirmed that the food provided at the home is varied and of a good quality. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 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.V339408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given clear information prior to admission to assist them to make a decision to move in. All Residents are visited prior to admission to ensure the home can meet their individual needs prior to them moving in. EVIDENCE: The home has had no further admissions since the previous inspection. Two residents chosen at random were spoken to regarding their initial admission to the home. Both stated that the Manager had visited them beforehand. Assessment details were kept within the care plans. One senior member of staff and the manager were spoken with about the admission procedure and how they make sure residents are welcomed. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 Page 9 Written information was adequate, with written information supplied by the social worker. Residents and their relatives are clearly given the required information to assist them to make a decision. The home does not offer intermediate care. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents or their relatives are involved when their care plan is compiled and reviewed to ensure that their individual needs are met. EVIDENCE: Each resident has their own personal care plan and two care plans were examined as part of the inspected. These contained comprehensive details of the residents’ health, social and mental health needs. A life story of the resident is included to assist staff with background information of family, hobbies, and previous employment. The care plans are developed around risk reduction and contain individual risk assessments to enable residents to live, as they should wish. The medication was observed during lunch time period being distributed satisfactorily by the senior staff in charge. It was recommended that the proprietor consider adding resident’s photographs onto the front of the MAR sheets to reduce the risk of drug error. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 Page 11 All staff have received recent medication training and evidence was seen in staff training files. Residents spoken with stated that they felt the staff were very respectful in their manner and were treated with dignity. ‘ The staff are like my family, they are always so patient and kind’. Observation during the site visit and past inspections provided evidence that residents were treated with respect by all the staff on duty. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can enjoy a varied and nutritional menu ensuring personal tastes are taken into account. Sociable activities are organised on a regular basis that take place during various times of day. Visitors are welcomed into the home by friendly polite staff. EVIDENCE: During the day many of the residents were seen either in their own rooms or within the lounges. Several were keeping themselves busy with their own occupation and hobbies. Staff were seen sitting talking to individual residents at various times during the day. Care staff continue to organise games, painting, knitting, writing letters, cards, bingo, singing, parties and the occasional outing to the local garden centre cafe or shop, and occasionally a resident helps with small household tasks around the home. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 Page 13 Several residents spoken to confirmed that activities were discussed while residents were all together after lunch. It was observed that staff respected those residents who did not wish to take part in activities and preferred to stay in their room. The home does not employ a cook; a senior member of staff is allocated to do the cooking. All staff have achieved the food hygiene certificate. The main dining room is in the conservatory, although several residents eat their meals where they wish, including their own rooms. At present there is a choice for the majority of meals, although one main meal at lunchtime with alternatives if requested. Adapted cutlery and crockery for use by some residents is also provided. The staff monitor residents’ weight to help ensure that their nutritional needs are met, which is good practice. Lunch was a relaxed and sociable occasion, with staff serving meals and assisting in a discreet manner. Several residents confirmed that meals were tasty and the amount of food was excellent and could not be improved. The kitchen was clean and tidy, and had recently been refurbished to a good standard. No relatives were seen during the day, but comment cards were received from 8 prior to the inspection, with the comments confirming that they were welcomed and were always offered to take tea with the resident. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are safely cared for by polite well-trained staff. Good procedures are in place to ensure all complaints are investigated adequately. EVIDENCE: The deputy manager confirmed that complaints were recorded and dealt with immediately, either by herself or the proprietor. A complaints policy is in place and a copy is kept in the front hall. No complaints were received during this visit and no negative comments were received from the comment cards prior to the inspection. The deputy manager explained the adult protection procedure. Senior staff confirmed that they were aware of the adult protection procedure and had attended training or completed distance learning training during the year. All staff spoken to were aware of the whistle blowing policy and the circumstances when this should be used. The 2 residents who were spoken to at length during the day had no concerns about the care they receive. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 Page 15 Staff records in respect of the deputy manager and senior carer were seen and showed evidence that adult protection had been included in their induction and ongoing NVQ training. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, comfortable home. EVIDENCE: A partial tour of the home showed that some improvements had taken place since the last inspection. The proprietors have recently replaced the entire kitchen, although minor tasks were still to be completed. The chair lift had also been replaced. The maintenance programme was included with the information sent prior to the inspection and the intention is for the hallway to be completed next. The hallway carpet did not need replacing, although there is a risk where the floor levels change. These have been changed from steps to small ramps. Adequate signage was in place. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 Page 17 The home was found to be clean and tidy with no observable hazards to residents. The proprietor reported that bedrooms were usually redecorated when they became vacant. Residents are sited on two floors and the proprietor’s office is located on the third floor. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are cared for by well-trained polite, friendly staff, the home increases the numbers of staff according to arranged sociable activities EVIDENCE: It was observed during this visit that staff carried on with their individual duties while others interacted with residents, spending time organising short sociable sessions. The rota provides cover over a two-week period. This showed that sufficient numbers of staff were on duty to ensure the residents’ needs are met. During the day of inspection both proprietors were in the building, although were not included on the rota. In addition, the the deputy manager, a senior carer, (who was on catering duty) and one carer were present. One senior carer was attending a training course. Residents stated that they ‘didn’t have to wait long if they wanted some help from the staff’. During the day it was observed that staff sat with residents and they confirmed that they could spend time with them. The rota confirmed that a senior member of staff was always on duty. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 Page 19 The proprietors organise an exceptional amount of training for the staff. Staff confirmed that they felt very well supported by them. Supervision takes place, which is cascaded down the staff group. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management arrangements are meeting the needs of residents and their relatives. EVIDENCE: Mr & Mrs Tripp manage the home, though have different areas of responsibility. They are both experienced providers and have managed the home for several years, providing good training opportunities and supervision of staff in order to promote good care for their residents. The home audits the quality of care provided and the results of the latest survey were seen. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 Page 21 The proprietors are responsible for some residents’ personal spending money and at the previous inspection it was recommended that for all financial transactions there must be two signatures in place to reduce the risk of error. This was checked and has been introduced. The proprietors hold regular meetings with staff, and involves senior staff with supervision sessions of the junior staff. Staff confirmed that the proprietor has an ‘open door’ and is open to good ideas for future planning. A random check of health and safety procedures was seen, such as fire risk assessment, training and moving and handling. Risk assessments are in place for individual residents care and the safety of staff and visitors. Records seen of the boiler, lift servicing and fire drills and electrical goods were satisfactory. The proprietors visit the home most days to provide ongoing support to residents, care staff and the deputy manager. Overall, the home has developed a good system for monitoring health and safety issues to provide a safe home to live and work in. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x x 3 Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations It was recommended that the proprietor consider adding resident’s photographs onto the front of the MAR sheets to reduce the risk of drug error. Kevlin DS0000027292.V339408.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V339408.R01.S.doc Version 5.2 Page 25 - 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!