Inspection on 18/01/08 for The Kensington

This inspection was carried out on 18th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Kensington 13/01/09

The Kensington 08/12/06

The Kensington 10/02/06

The Kensington 07/10/05

The Kensington 31/03/05

The Kensington 05/10/04

The Kensington 17/03/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Kensington The Kensington Care Home 340 Pelham Road Immingham North East Lincs DN40 1PU Lead Inspector Theresa Bryson Unannounced Inspection 18th January 2008 09:30 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 The Kensington DS0000035288.V358409.R02.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. The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Kensington Address The Kensington Care Home 340 Pelham Road Immingham North East Lincs DN40 1PU 01469 571298 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) sheilagh_kelly@yahoo.com Mrs Gurdial Kaur Kelley Sheilagh Margaret Kelly Care Home 37 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (37) of places The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. that the home is able to accept two service users under the age of 65 years that the lower age limit of the two service users under the age of 65 years is 60 years of age 8th December 2006 Date of last inspection Brief Description of the Service: The Kensington Care Home is a combination of old and new single storey buildings. The home is situated in the centre of Immingham close to local amenities, post offices, pharmacies, newsagents and public houses. The home is on a main bus route giving access to Grimsby, Cleethorpes and outlying villages. The home is registered to support and provide services to thirty-seven people who fall into the category of old age, fifteen of whom could experience problems associated with dementia. The district nursing services provide any nursing input services users need. The accommodation comprises of thirty-three single rooms, sixteen of which are en-suite and two shared rooms. Eleven of the single en-suite rooms are part of a new build that was completed at the beginning of 2004. The home has six bathrooms, two of which are equipped with walk-in showers and one of them has a Jacuzzi bath facility. There are two main lounges, one of which is situated in the new build, a separate dining room and a further small lounge, that is used for service users who wish to smoke. The home also has a small seating area close to the entrance that can be utilised as a quiet area for people to see their visitors. There are gardens to the front and rear of the home. The rear garden is a raised section accessible via a ramp and steps. In addition the home has an enclosed courtyard with garden furniture and a raised pond stocked with fish. There is ample car parking space at the front. According to information received from the home on 2.10.06 their weekly fees are between £329 and £372. Items not included in the fee are toiletries, hairdressing, chiropody and transport. This is reviewed annually and may have changed since this report was written. Information about the services the home provides is kept in each of the service users’ bedrooms. The Statement of Purpose and Service Users Guide are located near the front entrance and given to each prospective service user prior to admission. The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. The site visit for this service took place over two days in January 2008, on the 17th and 18th, and is part on an on going inspection process through out the year. Prior to the visit surveys were sent out to relatives and health professionals. The Annual Quality Assessment Audit documentation sent in by the home was also checked as well as the event history kept by us. 10 relatives were spoken to during the course of the site visit, plus 1 health professional, 4 people who are resident in the home and 11 staff. 3 other professionals who have visited the home recently were spoken to by telephone. A large selection of records and documents were checked during the site visit. Including tracking of peoples files who live at the home and staff. This enables us to see how accurately staff record events and what other agencies may be involved with the people who use the service. The Registered Manager was present through some of the site visit. We were accompanied mainly by the Care Manager. What the service does well: What has improved since the last inspection? The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 6 Since the last inspection the home had disposed of any chipped crockery and new pieces were in use, which ensures it is safe to eat from. The home was currently not using any bed rails for people safety, so no checks were having to be completed. The receiving of medication by the home from the Chemist is now recorded. What they could do better: Records which the home keeps to ensure all the current needs of people living in the home are being met were not up to date and relatives were generally not aware that they could help their loved ones to check them. A failure to do so could result in people living in the home being put at risk from their needs not being met. There was also some poor record keeping in the drug administration records and storage of drugs and this could result in people being harmed if there are not robust systems in place. Subsequent information was given that staff administrating medication have now been given fresh instructions by the home manager. The choices for social activities were very limited and when checking the diverse needs of people living in the home this aspect of their care was not being met. There was some variance in the menus on display and what people were receiving for meals. Food was prepared in a clean and safe environment. Failure to provide a nutritionally balanced diet could result in people becoming unwell. The management team were also asked to look into the staffing levels within the home as their were insufficient staff recruited to ensure all aspects of a person’s care could be met at all times. More training must also be given to staff to ensure that they at all times ensure people are treated with dignity and respect. The home has also been asked to review the recruitment policy for staff prior to any one commencing employment. The home must ensure that all safety checks have been completed to ensure staff are safe to work with people prior to starting work. They then must be trained in all aspects of looking after people to ensure they are free from harm. There was poor management support in the home and a number of failures to check processes in place to ensure the home was running for the benefit of the people living there and that all their needs were being met. This included little documented evidence on how the home was planning for the future, ensuring staff had adequate supervision to do their jobs and The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 7 auditing the written care plans of peoples’ needs. A failure to do so could result in people being at significant risk of harm. During a tour of the home some areas needed particular attention as they could pose a significant risk if left unchecked. For example the water temperatures were too low to wash in and carpet in one lounge was potentially going to cause a trip hazard as it was rucked in an area where people continually walk. Subsequent information was given that these items have now been addressed. A number of concerns had been raised about the laundry service provided, causing people a lack of dignity and respect when items of clothing were damaged, lost or they had to use substandard towels and bed linen. At the site visit it became necessary to refer two serious breaches of Regulations to the local safe guarding team. These could both potentially cause the people concerned to be at risk from harm. 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. The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 8 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 The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 9 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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 3 and 6 were checked. A comprehensive tool is used to assess people prior to admission to make sure the home can meet their needs. EVIDENCE: Prior to admission a member of the management team assesses each person prior to admission. The assessment is very holistic and covers all aspects of a person’s life, medical and mental health history. This is then used as a basis to plan the care for that person and ensure the home can meet their needs. The home does not provide intermediate care, so Standard 6 is not applicable. The Kensington DS0000035288.V358409.R02.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 adequate. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 8, 7, 8, 9 and 10 were checked. The care plan recording by staff needs to be accurate to reflect the current needs and problems of each individual to ensure they are free from harm. EVIDENCE: Prior to the site visit surveys were sent to relatives and health professionals, as most of the people resident in the home cannot make informed decision. There was a poor response to us. Over the two days of the site visit we were able to speak to 10 relatives and 4 people who live in the home as well as one health professional in person and one by telephone. The general comments from relatives were that staff are pleasant but they have been concerned when messages are not passed on and there has been a great lack of communication when their loved ones have fallen or had other The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 11 accidents. Requests for monitoring such as fluid intake and maintaining a healthy diet appear not to have been passed on at times and relatives have approached members of the management team before the requests have been actioned. This could result in people being put at risk and not having needs met by staff. Only one of the relatives was aware that they could have some input in the care plan reviews of their loved ones and there was a lack of evidence in the 4 care plans tracked. The home does have documentation for people to complete but there was no evidence to support this was actioned. It is particularly important that staff ensure relatives can have this input when people living in the home cannot make informed decisions about their lives, to ensure care is being delivered that meets their needs and expectations. Of the 4 care plans tracked there was a lack of consistency in the documentation in use, which is confusing for staff as they are writing different ways in each document and there could be a risk of needs and events being missed. The majority of the documentation was very task orientated still but this has been reviewed in the last year, as previously there was no documentation and staff are still being instructed on how to complete accurate records to ensure each person’s needs are met. There was also a lack of consistency in the way accidents are recorded and in one case an event recorded of bruising seen had not been accurately recorded in the untoward incidents, senior management in the home had not been informed, CSCI had not been informed and neither had the safeguarding adults team. This is a serious breach of the safeguarding adults’ protocol and has now been passed to that team by CSCI. This could put people at serious risk of harm if senior staff in the home and the safeguarding team does not monitor events such as this. In conversation with some relatives they were concerned that those with memory loss were not having the observation and supervision they required. For example when sitting with one family they were changing their loved ones socks as staff had failed to notice the person still had bed socks on and the bootees they were wearing were cutting into the person’s leg. Another person stated “one of the reasons mum is here is because she needs help to dress and yet I can come in the afternoon to find she has two vests on and a skirt which isn’t her”. This has resulted not only in staff not delivering care but a lack of respect for residents’ well-being. Staff were observed during the day giving personal care to people, taking part in activities and assisting people at mealtimes. At times the voice tone of staff was loud and they appeared to give abrupt instructions rather than ask a person what they wanted to do or state what was happening. During the last year there have been 2 safeguarding adults referrals concerning the way staff have spoken to people. These had been addressed by the internal The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 12 management team, but still needs careful monitoring to ensure people are treated with dignity and respect. There was differing opinion of relatives on this issue, some stated “staff are pleasant” and others “some staff speak sharply”. This indicates the problem is not yet fully resolved. The home can take people for day care and currently only has one person on their books. There was no indication on the rota system of what staff member is allocated to them when they are present in the building. This indicates that a staff member is taken from the numbers for more permanent people resident in the home, which could compromise the care being delivered to each individual. A senior member of staff assisted us in checking the medication records. The storage area was very small and there were no records to support that temperature checks were being completed. Some temperature records have since been sent but will need to be checked at the next inspection for continuity. Failure to do so could result in medication being stored at an incorrect temperature and be unsafe to use putting people at risk. The area was tidy and the trolleys clean. On checking the drug administration sheets it was discovered that staff have failed to indicate why some medication times had been altered and could not give an adequate explanation to us. Staff cannot alter a prescription and this could result in medication being given inappropriately and put people at risk from harm. Subsequent information was sent to us to ensure this has been corrected. The home needs to produce evidence that they are ensuring due diligence with peoples medication and have requested a review by medical practioners. 2 relatives stated to us that they were concerned about comments from staff when medication has been changed, as they felt their loved ones were showing altered behaviour. Staff when challenged by us stated they had no knowledge of medication changes and the current drug administration sheets did not indicate any new medication. The manager was asked to look into this and complete a full medication audit for each individual and to check staff’s knowledge base and the way medication is administered. Failure to administer medication correctly could result in people being significantly harmed by staff. On checking the controlled drug cupboard two packets of unnamed tablets were discovered in clear plastic bags, the staff had no knowledge about them and the manager was asked to investigate this and remove the tablets. Subsequent information was sent to show the manager has given fresh instructions to staff. The controlled drugs cupboard must only be used for that classification of drugs. The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 13 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 adequate. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 12, 13, 14 and 15 were checked. Social activities need to be expanded to ensure people’s expectations are being met and their must be more choices provided on the menu to ensure people are getting a balanced diet. EVIDENCE: At the time of the site visit the management team were still seeking to recruit an activities co-ordinator. Staff from the allocated care numbers were trying to fulfil individuals needs on a daily basis. This could result in care needs being unmet if staff numbers are then compromised. The written records showed that each person had received an assessment on their social, cultural and religious needs, but the documentation evidenced on daily events was very repetitive. The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 14 Each day of the site visit an activity was taking place but this tended to be in a large general sitting area and people did not have the opportunity to not participate. A relative was concerned that the majority of activities were not based at a level their loved one could participate in and another stated, “staff seem to be short of ideas”. On tracking some care plans and speaking to relatives it appeared that people came from diverse backgrounds and had varying degrees of memory loss. The activities recorded did not take those elements into consideration and people’s expectations and needs appeared not to be met. On touring the kitchen food was prepared in a clean and safe environment. All equipment was in working order and all chipped crockery replaced since the last inspection. The environmental health officer had visited in June 2007 and all items requested by them appeared to have been completed. It is recommended that the new pantry shelves have some covering, which can be wiped, as the natural wood is becoming stained and difficult to keep clean which could cause a health risk. Comments from relatives who had seen the meals provided stated they felt the portions were enough, it was nicely presented and their loved ones had not lost any weight. The cooks’ menus were seen and the kitchen staff were able to detail the needs of individuals in the home. This included special diets for those requiring high fibre content and those suffering from diabetes. The menus seen in the kitchen did not however bear any resemblance of those on display for residents and relatives to see. This practise has since been corrected and new menus submitted to us. Failure to provide an adequate menu could result in people not having a balanced diet and be detrimental to their health and well being. The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 15 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 poor. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 16 and 18 were checked. There is no robust system in place for reporting untoward incidents, which could put the people at serious risk of harm. EVIDENCE: Prior to the site visit the home submitted an AQAA document stating how many complaints and safeguarding issues had occurred in the last year. On checking the safeguarding referrals it was discovered that 3 had been made against the home but we were only aware of 2. The safeguarding team had signed off all three, with no further action required. On checking the care documentation for one person living in the home there was written evidence to support that a further safeguarding referral should have been made to the local team and us. The management team had failed to do so and the referral was made during the site visit to the local team by us. This referral was coupled with a second concern raised by us during the site visit of a possible breach of expenditure of people’s personal money for environmental repairs at the home. Failure to follow the safe guarding protocol could put people at serious risk of harm if not investigated fully. The home has failed to do so on this occasion. The Kensington DS0000035288.V358409.R02.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 adequate. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 19 and 26 were checked. Attention to detail is required to ensure people are living in a safe and secure environment. EVIDENCE: During the course of a two day site visit we were able to tour the home unaccompanied and also with the care manager. The home was of an acceptable level of cleanliness and the home employs daytime cleaning staff. There was written evidence to support that night staff are asked and sign to say they have completed a number of nighttime cleaning jobs. This part of their job description must be reviewed, as the designated care hours are to attend to the needs of people living in the home and could compromise their care if staff are distracted from their jobs. The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 17 Whilst speaking to relatives and people living in the home there were numerous concerns raised about the standard of laundry services provided. This included missing items (for which people had not been reimbursed), damaged clothing, items not ironed and poor standard of repair of towels. During the course of the visit one serious concern was fed back to the manager who dealt with the matter in a couple of days. On touring the home the towels and some bed linen were of a poor standard and some bed linen was being stored on the floor of one cupboard. The inadequate standards provided by the home in this area could compromise the dignity and respect to people living there if they cannot wear their own clothing or have to wear damaged or non ironed items. Whilst touring the home it was observed that some doors were wedged open, which compromises the fire safety guidance and could put people at risk should a fire occur. And some doors were sticking on the carpet and would not close easily should there be a fire alarm call. The manager was asked to attend to this as soon as possible. It was also observed during the tour of the home that one sitting room carpet was seriously rucked and could cause a trip hazard. In another area a clothes rail had been left in a bath and could easily topple onto a person, as it was so unstable. Subsequent details were sent to show that these matters had been addressed and instructions given to staff. These all present very real hazards for the people living in the home. The management team must ensure that an environmental check is completed and all areas are safe to live and work in. Work must be prioritised and staff instructed to make regular checks of the building. Due to very poor weather conditions we were unable to tour the garden area, but immediate exit areas were free from hazards. The Kensington DS0000035288.V358409.R02.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 poor. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 27, 28, 29 and 30 were checked. Recruitment practises are not robust enough to ensure the safety of people living in the home. EVIDENCE: As stated in other parts of the report staff are taken away from their caring roles on a regular daily basis to fulfil other roles. This includes kitchen duties at teatime, social activities through out the day and cleaning tasks at night. Staff themselves commented “it’s difficult at teatime” and “hectic early in the morning shift”. The management team are currently looking in to this issue and have sent us written documentation to show they are actively looking for an activities person and revised the night staff duties. Failure to ensure the correct staffing numbers for the dependency of people living in the home could put them at risk from being harmed and needs not being met. Written evidence was seen that staff had mostly completed all mandatory training and some specific to peoples needs currently in the home. This included dementia awareness and infection control. Staff stated how they had The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 19 “welcomed” this amount of training and “there were always opportunities to do training”. On tracking 7 personal files of staff there was not sufficient evidence in some to prove that adequate safety checks had been made prior to the commencement of their employment. This included insufficient references and a lack of recorded challenge to positive Criminal Records Bureau disclosures. Failure to ensure staff are safe to work with people before commencement of employment could put them at risk from harm and staff issues individually notified to the manager must be addressed as soon as possible, to protect the people currently in the home. Documentation was later sent to show the management team were correcting this matter, this included further references, check on CRB disclosures and application forms. The Kensington DS0000035288.V358409.R02.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 poor. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standards 31, 33, 35, 36, 37 and 38 were checked. The home has failed to ensure it is a safe and secure environment in which people can live and work. EVIDENCE: During the course of the site visit it was brought to our notice that the Registered manager is only present in the home 2 days a week and this has been the case since July 2007. They also run other parts of the Company business. There was also no evidence to support that the Registered Provider visits the home and no Regulation 26 had been completed, to assure us that the owners The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 21 visit and monitor the home regularly. This remains an outstanding requirement from the last inspection. We tracked a number of records and documentation whilst on the site visit and there had been a failure to report and record outcomes from some issues seen. This included; - water temperatures running very low and no written evidence to support staff had seen the original policies and procedures or updates. Items such as those listed could put people at risk from living in an unsafe environment with little management control and oversight. Staff supervision records were in place and 7 sets seen. There appeared to be no observational supervision recorded and due to the comments by visitors and observations during the site visit, this part of supervision needs to be a priority for the management team to ensure staff can do their jobs correctly and not put people at risk. On checking the Comfort fund which people resident in the home, visitors and relatives had contributed to to provide social activities for people, written evidence was seen that last year money had been taken out to provide equipment which should have been supplied by Company funds. This matter has been referred to the Safeguarding Adults team for investigation. The management team also had no understanding of this account and although staff were able to give a good verbal account of how it runs there was no evidence to support the management team had audited this account, which could result in fraudulent use of peoples funds. Evidence has subsequently been produced that an audit has taken place and will be checked again at the next inspection. The lack of management control in the home is currently making this a possible unsafe environment in which to live and work and the Registered Provider must prioritise the Requirements listed and take action as soon as possible. Failure to do so could result in people being put at risk of harm. The Kensington DS0000035288.V358409.R02.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 2 8 3 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 2 2 2 The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15.1. Requirement The registered person must ensure that all care plans reflect the need to maintain existing skills. (Previous timescale of 31/01/07 not met). The management team must ensure that care plans are audited to ensure they are accurate records of the delivery of care to ensure current needs are being met. Staff must ensure that people using the service or their advocates have seen the care plan documentation and agree to the plan of care and there is written evidence open for inspection. There must be sufficient staff on duty to ensure that adequate staff can attend to the needs of day care when they attend the home, to ensure all their needs can be met and those of the people living there are not compromised. Timescale for action 30/03/08 2 OP7 15.2.b. 30/03/08 3 OP7 15.1. 30/03/08 4 OP7 18.1.a. 28/02/08 The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 24 5 OP9 13.2. 6 OP9 13.2. 7 OP10 12.4.a. 8 OP12 18.1.a. 9 OP12 16.2.n. 10 OP18 13.6. 11 OP19 23.4.a. 12 OP19 23.2.b. The room temperature of the drug storage area must be recorded regularly to ensure all medication is stored correctly. This will prevent unsafe medication being given which could harm people. A full audit must be completed by the management team of everyone’s medication, with medical assistance. To ensure each person is being given the correct medication for their individual conditions. Staff must receive instruction on how they address and conduct themselves to preserve each person’s dignity and respect. There must be sufficient staff on duty to ensure peoples social, cultural and religious expectations are met at all times. There must be sufficient variety of activities available to meet each person’s social, cultural and religious needs. Staff must receive updated training in how to refer safe guarding adults issues to protect people from harm. The Registered Provider must at all times ensure that the fire safety procedure has not been breached to ensure people are safe if fire breaks out. This is to include checking doors can be closed and wedges in doors are not in use. The Registered Provider must ensure that sufficient staff are on duty to maintain the cleanliness of the home, with out compromising the work of care staff, particularly with domestic jobs they are required to do at night. DS0000035288.V358409.R02.S.doc 28/02/08 30/03/08 30/04/08 28/02/08 30/04/08 30/03/08 28/02/08 30/03/08 The Kensington Version 5.2 Page 25 13 OP26 16.2.b. 14 OP27 18.1.b. 15 OP35 25.2.c. 16 OP35 25.2.c. 17 OP36 18.2. 18 OP37 26.1and 2.b. and 3 and 4.a.b.c. 23.2.b.c. 19 OP38 The provision of laundry services must be reviewed to ensure peoples clothing is not lost, it is ironed, and linen is of an acceptable standard and items reimbursed when damaged. This will help to preserve individuals dignity. The registered person must ensure that staffing levels consistently reflect the needs of service users. (Previous timescale of 31/01/07 not met). The Registered Provider must ensure that all money in the Comfort fund is only used for the benefit of people living in the home and not to supply equipment to maintain the fabric of the building. The Registered Provider must audit the Comfort fund records to ensure there is no fraudulent use of funds. The management team must ensure that each staff member has received adequate supervision and this must include some recording of observational supervision. This will ensure they are safe to work with people living there. The registered person must ensure that monthly reports of visits to the home are completed and available for inspection. (Previous timescale of 31/01/07 not met). The management team must ensure that water outlets used by people living in the home are safe to use and meet the required temperatures. Currently these are recorded as too low and could cause people distress when using water to wash or bathe. DS0000035288.V358409.R02.S.doc 30/03/08 28/02/08 28/02/08 28/02/08 30/04/08 28/02/08 28/02/08 The Kensington Version 5.2 Page 26 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 OP15 Good Practice Recommendations It is recommended that the pantry wooden shelves have some sort of covering which will enable staff to wipe them down to stop the risk of poor hygiene standards. The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB 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 The Kensington DS0000035288.V358409.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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