Latest Inspection
This is the latest available inspection report for this service, carried out on 15th December 2009. it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.
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.
For extracts, read the latest CQC inspection for Kenbrook.
Annual service review
Name of Service: Kenbrook The quality rating for this care home is: The rating was made on: two star good service 1 7 1 1 2 0 0 8 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.
Has this annual service review changed our opinion of the service?
No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Judith Brindle Date of this annual service review: 0 6 1 1 2 0 0 9 Annual Service Review Page 1 of 9 Information about the service
Address of service: Kenbrook 100 Forty Avenue Wembley Middx HA9 9PF 02089045818 Telephone number: Fax number: Email address: Provider web address:
kenbrook@mha.org.uk www.mha.org.uk Methodist Homes for the Aged Name of registered provider(s): Conditions of registration: Category(ies) : old age, not falling within any other category Conditions of registration: Number of places (if applicable): Under 65 Over 65 0 52 The maximum number of service users who can be accommodated is: 52 The Registered Person may provide the following categories of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Kenbrook is registered to provide nursing care in all its beds. The home has been run by Methodist Housing Association from the 5th December 2007. The home is found on Forty Avenue and is easily accessible by car and by public transport. There is a bus service, which passes in front of the home. The nearest underground station is Wembley Park. There are shops at about five minutes walking
Annual Service Review Page 2 of 9 1 7 1 1 2 0 0 8 distance from the home and one can catch a bus into Wembley for a wider variety of shops and for local amenities. The building is spread over a relatively large area and consists of two floors. There are maintained gardens on all sides of the homes and there is a car park in front of the home. The living accommodation is found on two floors along long corridors with rooms on either side. Each resident has a room, with a washbasin and a small area for personal care. Toilets and bathrooms are communal and are found on each floor. The home is run as a main unit, but the number of residents is divided into three groups, each of which is looked after by a team of care staff supervised by the nursing staff. Information about the service and the fees can be obtained from the home. Annual Service Review Page 3 of 9 Service update since the last key inspection or annual service review:
What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection that took place on the 17/11/08. This included; looking at the annual quality assurance assessment (AQAA) that was sent to us by the service within the timescales set by us. The AQAA is a selfassessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We also looked at eight feedback surveys completed by staff, five from people using the service, nine from relatives of people using the service, and two from a health and social care professionals. Information we have about how the service has managed any complaints, and what the service has told us about things that have happened in the service, these are called notifications and are a legal requirement were also looked at. We assessed the previous key inspection report and relevant information from other organisations was also considered. We spoke with the deputy manager of the service during this review. There were nine requirements from the previous inspection, which the deputy manager and the AQAA told us had been met by the service. We thank all those who provided us with feedback about the service during this annual service review of Kenbrook Nursing Home. What has this told us about the service? We received the AQAA (Annual Quality Assurance Assessment), prior to this review. This document had been completed very comprehensively by the registered manager and gave us all the essential information about the service that was asked for, and indicated that the home has a good knowledge and understanding of the National Minimum Standards for Older People. The AQAA included examples to demonstrate how positive outcomes are supported and enabled for the people using the service.Key points within the AQAA included reference to listening to, and supporting people using the service to make decisions about their lives. AQAA told us about the systems that are in place to gain the views of people using the service and others; an annual Resident Satisfaction Survey is conducted by an independent external company and results are analysed and an action plan developed to make improvements and share good practice. We were also told service users are invited to join our Governing Body (1/6 is made up of those using our services), thus enabling them to contribute to MHAs strategy and decision making, and monthly resident meetings and three-monthly relative meetings are held where individuals are encouraged to participate and discuss their views which are then incorporated into improvements in the service delivery. AQAA also told us that the Manager, Deputy Manager and Team Leaders have daily contact with service users so feedback on the care and support offered to service users is obtained. Also We have a two part internal quality assurance system which involves talking with service users and ascertaining their views and experiences, and action plans are implemented to improve the service provided to service users. We were told of developments that had been made to the service as a result of Annual Service Review Page 4 of 9 listening to people.These include; developing the number and variety of activities (including individualised personal activities, and providing more reminiscence and multi sensory materials), devising a whole new menu, and offering more opportunities for ensuring that residents spiritual needs are met by the service. We were told that the care home has an equal opportunities policy/procedure, and staff receive training in equality and diversity. We were given (recorded in the AQAA) numerous examples of how the equality and diversity needs of people using the service are met.These include; providing meals that meet peoples religious and cultural needs, having other key policies around freedom from harassment, protection from abuse and cultural, ethnic and religious needs, and assessing and admitting people to the home entirely based on their need, and irrespective of their background, beliefs, culture or sexuality. We were also told Kenbrook caters for older people with a variety of disabilities which we aim to ensure do not prevent them from enjoying a fulfilling life with us. One person commented via a feedback survey more English food is required, another told us that the meals are nice. Some staff told us via the feedback surveys that they sometimes feel that they have enough support to meet peoples equality and diversity needs. The manager should look into possibly further education/training for staff with regard to this. Previous inspection told us that Kenbrook Nursing Home has up to date information (statement of purpose and service user guide) about the service that it provides, and that this documentation is available to people using the service and to others. We were also told by the AQAA and the deputy manager that all residents receive a contract of terms and conditions. We were told from previous inspection and the AQAA that prospective residents receive a comprehensive assessment of their needs (with their full involvement) before they move into the home, and that each person using the service has a person centred plan of care which is regularly reviewed. The deputy manager told us that residents (and or relatives/friends) are fully involved in their plan of care. Feedback via a survey form from a social care professional told us that people using the service always receive an assessment of their needs, their health and social needs are monitored, and staff have the right skills and experience to support peoples needs. AQAA told us that staff have an knowledge and understanding of the importance of ensuring that people using the service are respected. We were told as part of the completion of their care plan, service users are asked about their end of life wishes and these are recorded and that this is considered as being of the utmost importance and staff and relatives wishing to offer comfort and support to a dying service user are enabled to do so. Overnight facilities are available to relatives or friends who wish to remain close to a service user during their final days. The deputy manager told us that the GP is made aware of the end of life wishes of each person, when this becomes a need. This is positive. A relative of a person using the service told us that their relative was having her needs met perfectly by the home. We were told from the AQAA, that people using the service are supported to take part in the activities, and leisure pursuits of their choice, and that they are fully involved in making decisions with regard to these. We were given examples of the numerous contacts that the home has with the local community including developing links with local schools, and places of worship. We were informed from the AQAA, that there were plans to employ an activity worker. People using the service told us via feed back
Annual Service Review Page 5 of 9 forms that the home arranges activities that they can take part in. A relative of a person using the service told us via a feedback survey that there could be more entertainment for people using the service, another person commented there could be more activities and stimulation for the residents. A relative of a person using the service informed us that they would like more personal related exercises and a womens only group memory classes. A staff member told us that the home should employ an activities co ordinator dedicated to doing different things with residents, other staff told us that residents could have more opportunity to participate on trips out, and to go on more walks. The deputy manager spoke of the recent developments and improvements made with regard to improving the access and choice of activities, and told us on going improvements were being made. AQAA told us that the health needs of people using the service are met, and they have access to care and treatment from a variety of health care services, including access to specialist medical, nursing, dental, pharmaceutical, chiropody, therapeutic services and care from hospitals and community health services and we were told service users are also able to maintain the services of their usual GP or registered with a GP of their choice. Previous inspection told us that Kenbrook has a medication policy/procedure, and that staff who administer medication are trained and competent to do so. The deputy manager told us that the previous requirement with regard to administration of medication, had been met by the service. Feedback from a health care professional told us that medication is always administered correctly, and that the home respects peoples dignity and privacy and staff have the right skills and experience to support peoples social and health care needs. Feedback from surveys we received from people using the service told us that they were asked if they wanted to move into the home, and they received enough information about the home before they moved in. Residents told us that the home is fresh and clean, they generally (some people told us that staff sometimes or usually act upon what they say) can do what they want to do during the day, and they know who to speak to if they are unhappy. We were told staff treat them well,and listen to what they say and one person told us that the home is well managed, and gives its best. Comments from a relatives of a people using the service told us the residents are very well looked after, I am made to feel welcome and the manager is very good, very friendly caring environment, very welcoming to visitors, the staff are always warm and smiling, which makes the home extremely comfortable, the food is good quality and very adequate in terms of quantity, staff respond well to the needs raised by residents, my (relative) is treated with respect and kindness and her dignity and self respect maintained, and there is a good response to any requests for (my relatives) well being from staff. Previous inspection and the AQAA told us that the home has a complaints procedure, and robust Protection of Vulnerable Adults policy, and that Kenbrook has introduced guidance and training in the Mental Capacity Act (and deprivation of liberty safeguards) to ensure residents rights are paramount and no decisions are made for people who lack capacity. We were told that there had been three complaints within the last twelve months, and these had all been resolve within 28 days. AQAA told us that there had been three safeguarding referrals made, and all staff receive safeguarding adults training. The deputy manager told us that she was confident that all staff knew how to respond if there was a suspicion or allegation of abuse. People using the service told us
Annual Service Review Page 6 of 9 that they knew how to make a complaint, and staff told us that they knew how to respond to a complaint and/or concern. The AQAA told us that the care home recruits staff appropriately, retains staff, and staff receive appropriate training including an induction to carry out their role and responsibilities in meeting the needs of people using the service. We were told by the deputy manager that the requirement with regard to recruitment of staff had been met by the service. We were told that 85.6 percent of our care assistants are NVQ Level 2 trained. 92 percent have at present completed mandatory training and 79 percent of staff have had training in Safeguarding of Adults, and all staff will have had training in Mental Capacity/Dementia by the end of February 2010. We were informed by the AQAA that staff have a key working role and have the opportunity to attend regular team meetings. Feedback from two people using the service, and a relative of a resident told us that they felt that there could be more staff. Staff feedback told us that there was usually or sometimes enough staff to meet the needs of people, and a staff member told us that training could be better. Staff feedback surveys told us that staff are always given up to date information about the needs of the people using the service, their induction covered all or mostly what they needed to know to do the job when they started, and they are provided with training that is relevant to their role, and helps them to understand and meet the needs of people using the service. Staff also told us that they are always or usually given enough support. Comments from staff included I think it is a quality care nursing home, the home has all the equipment (needed) like hoists, wheelchairs etc, the home is a good place to work, residents are well care for, and are happy, respected and given choice, Kenbrook is a very happy place to work in, the home supports and cares for residents very well. We were told from the AQAA that the environment of the home is suitable for its purpose, and there are plans to develop all of the rooms to incorporate en-suite facilities for service users, and improvements to the dining and seating lounges are planned. We were also told that within the last twelve months there had been refurbishment of 10 bedrooms on the first floor, new electric profiling beds had been purchased, a new call bell system had been installed, and new restaurant style dining room facilities have been put in place. A relative of a person using the service told us that sometimes the lounge is so hot its unbearable. The manager should look into this issue, and monitor the temperature of the room. AQAA told us that the home has received a 5 star rating from the Environmental Health Department. The home has systems in place to ensure that safety checks are carried out in the home, policies and procedures are generally up to date, though some are dated 2003, 2005 & 2006 and should be reviewed. We were told that appropriate monitoring of the service takes place, including monthly checks (audits) carried out by a representative of the Organisation. The manager is competent and experienced in running Kenbrook Nursing Home. We spoke with the deputy manager during this review, who told us that the requirements from the last key inspection had been met. She also told us that on-going improvements and developments to the home continue to be made. Comments from a person using the service told us that the home is efficiently run by trained staff. Feedback from relatives of people using the service told us staff are helpful and
Annual Service Review Page 7 of 9 friendly, I am satisfied with the care my (relative) is getting in the home, the management is excellent, and always there when help is needed. A staff feedback survey told us that system of management in the home was good. What are we going to do as a result of this annual service review? It is evident from the information received about the care home since the key unannounced inspection (17/11/08) that our judgement is that the nursing home is still providing a good service to people using the service. However we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 8 of 9 Reader Information
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