Care Home: Kendal House

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What the care home does well Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 6Staff have developed warm and caring relationships with the people in their care. Staff are patient, kind and considerate and are enthusiastic about their jobs. Staff are knowledgeable about people’s needs and how to meet them. The owners of the home are involved in the day-to-day running of Kendal House and are committed to its continuous development. The providers, manager and their staff team provided every assistance throughout the inspection and worked in a positive manner with the inspection process. The home is well-maintained, clean, warm, comfortable and safe. Kendal House provides notice boards in the reception hallway displaying information about events and activities taking place within the home. People using the service said they are provided with very good care that meets their needs. People spoke very highly of the home and its staff. Over 76% of the care team have obtained a recognised qualification in care. A member of the domestic team has obtained a recognised qualification in housekeeping. Staff that returned surveys said: ‘The service constantly strives to meet residents’ individual needs. The home is always maintained to a high standard and there is a friendly homely atmosphere.’ ‘I think the home is run to a very high standard.’ ‘The management are always there when I need them for anything. I am seen by the manager every six weeks for updates on how I am doing my job.’ ‘We always listen to our clients and their families. We always do the best we can and if I can make someone feel safe, happy and secure, then I feel that I have done my job well and I feel happy.’ People living at the home that returned surveys said: ‘I am quite happy here – you always have company and there are always people to talk to if you are worried about anything.’ ‘I am alright here. I am happy and well looked after.’ Health care professionals who returned surveys said:‘A well-run family style home. Staff are warm and welcoming and readily offer information. The district nursing service has a good working relationship with staff.’ ‘Staff appear to know service users very well and are quick to respond to any problems that occur. I also feel that the staff are very approachable.’ ‘The Kendal House team has the ability to turn a care home into a person’s own home. They provide comfort, support and always give that personal touch. The residents appear to be settled and happy. Care is of the highest degree. The home is always clean and food choices are good.’ ‘The home just about does everything well. Staff are always well aware of any wishes or problems of their residents. Good lines of communication with me as a GP make for a high standard of care.’ Another GP said that their practice has an excellent relationship with the service. A social work professional said: ‘The home is always clean. Staff are very professional and friendly. Residents are respected and treated with dignity. Individual needs are met.’ What has improved since the last inspection? Staff statutory training has been updated. Some senior staff have recently completed Mental Capacity Act training. Staff hours have been increased to enable more one-to-one activities with service users to take place. Extra equipment has been purchased to enable staff to provide a wider range of activities. The home’s hospital admissions procedure has been amended to enable the smooth transition of people from Kendal House into a hospital setting where necessary. A range of improvements has been made to the premises. For example, all doors have been replaced to provide wider door openings. All doors have been repainted. The home has been redecorated. A new grill, fridge and boiler have been purchased for the kitchen. Garden equipment has been purchased to improve the home’s external areas. The roof has been completely replaced and UVPC windows have been fitted throughout. What the care home could do better: Ensure that all staff employed post April 2002 have provided a full employment history. This will help to ensure that only suitable staff are employed at the home. CARE HOMES FOR OLDER PEOPLE Kendal House 29 Park Avenue Whitley Bay Tyne & Wear NE26 1DP Lead Inspector Glynis Gaffney Key Unannounced Inspection 15 January 2009 10:30 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 Kendal House DS0000000307.V378876.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. Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kendal House Address 29 Park Avenue Whitley Bay Tyne & Wear NE26 1DP 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) 0191 2970093 F/P 0191 2970093 angela@kendalhomes.co.uk www.kendalhomes.co.uk Kendal Homes Limited Mrs Angela Oliver Care Home 24 Category(ies) of Dementia (4), Old age, not falling within any registration, with number other category (20) of places Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Date of last inspection 08 November 2006 Brief Description of the Service: Kendal House is a privately owned care home which offers residential care for up to 24 people over 65 years, some of whom may have dementia. Accommodation is provided over two floors within four converted Victorian terraced houses located near the town centre of Whitley Bay. There is a pleasant garden to the front of the building. To the rear there is a paved patio area with a pleasant seating area for service users and visitors. This is reached via the conservatory. Metered parking is available on the opposite side of the road and there is limited parking to the rear of the building. There are 23 bedrooms available in Kendal House, 12 of which offer en suite facilities. Communal toilets are situated throughout the building and there are two bathrooms both with hoisting equipment and an adapted shower room. First floor accommodation can be reached by a passenger lift. Kendal House does not provide nursing care. The cost for the service is £422.90 - £438 per week. Chiropody, hairdressing and newspapers are additional. Copies of the home’s inspection reports are available in the main reception area. Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. How the inspection was carried out: Before the visit: The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. We looked at: • • • • • Information we have received since the last key inspection visit on the 8 November 2006; How the service dealt with any complaints and concerns since the last visit; Any changes to how the home is run; The manager’s view of how well they care for people; The views of people who use the service and their relatives, staff and other professionals. The Visit: An unannounced visit was made on the 15 January 2009. During the visit we: • • • • • • Talked with people who use the service, some of the staff and the manager; Looked at information about the people who use the service and how well their needs are met; Looked at other records which must be kept; Checked that staff had the knowledge, skills and training to meet the needs of the people they care for; Looked around the building to make sure it was clean, safe and comfortable; Checked what improvements had been made since the last visit. We told the providers and manager what we found. What the service does well: Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 6 Staff have developed warm and caring relationships with the people in their care. Staff are patient, kind and considerate and are enthusiastic about their jobs. Staff are knowledgeable about people’s needs and how to meet them. The owners of the home are involved in the day-to-day running of Kendal House and are committed to its continuous development. The providers, manager and their staff team provided every assistance throughout the inspection and worked in a positive manner with the inspection process. The home is well-maintained, clean, warm, comfortable and safe. Kendal House provides notice boards in the reception hallway displaying information about events and activities taking place within the home. People using the service said they are provided with very good care that meets their needs. People spoke very highly of the home and its staff. Over 76 of the care team have obtained a recognised qualification in care. A member of the domestic team has obtained a recognised qualification in housekeeping. Staff that returned surveys said: ‘The service constantly strives to meet residents’ individual needs. The home is always maintained to a high standard and there is a friendly homely atmosphere.’ ‘I think the home is run to a very high standard.’ ‘The management are always there when I need them for anything. I am seen by the manager every six weeks for updates on how I am doing my job.’ ‘We always listen to our clients and their families. We always do the best we can and if I can make someone feel safe, happy and secure, then I feel that I have done my job well and I feel happy.’ People living at the home that returned surveys said: ‘I am quite happy here – you always have company and there are always people to talk to if you are worried about anything.’ ‘I am alright here. I am happy and well looked after.’ Health care professionals who returned surveys said: Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 7 ‘A well-run family style home. Staff are warm and welcoming and readily offer information. The district nursing service has a good working relationship with staff.’ ‘Staff appear to know service users very well and are quick to respond to any problems that occur. I also feel that the staff are very approachable.’ ‘The Kendal House team has the ability to turn a care home into a person’s own home. They provide comfort, support and always give that personal touch. The residents appear to be settled and happy. Care is of the highest degree. The home is always clean and food choices are good.’ ‘The home just about does everything well. Staff are always well aware of any wishes or problems of their residents. Good lines of communication with me as a GP make for a high standard of care.’ Another GP said that their practice has an excellent relationship with the service. A social work professional said: ‘The home is always clean. Staff are very professional and friendly. Residents are respected and treated with dignity. Individual needs are met.’ What has improved since the last inspection? Staff statutory training has been updated. Some senior staff have recently completed Mental Capacity Act training. Staff hours have been increased to enable more one-to-one activities with service users to take place. Extra equipment has been purchased to enable staff to provide a wider range of activities. The home’s hospital admissions procedure has been amended to enable the smooth transition of people from Kendal House into a hospital setting where necessary. A range of improvements has been made to the premises. For example, all doors have been replaced to provide wider door openings. All doors have been repainted. The home has been redecorated. A new grill, fridge and boiler have been purchased for the kitchen. Garden equipment has been purchased to improve the home’s external areas. The roof has been completely replaced and UVPC windows have been fitted throughout. Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 8 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. Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 9 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 Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 10 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. There are suitable arrangements for making sure that people’s needs are assessed before they are admitted into the home. This means that people using the service can be confident that staff will know how to meet their needs. EVIDENCE: People’s needs are assessed before admission into Kendal House. All of the records checked contain a social services assessment as well as a copy of the home’s own pre-admission assessment. The information obtained by the home helps the providers and manager to make an informed decision about whether they are able to offer people suitable placements. People spoken with during the inspection said that they thought their admission into the home had been well managed. Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 11 Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 12 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. The arrangements for meeting people’s health and personal care needs are good. This means that people are able to benefit from living in a home where their health and well-being is promoted and treated seriously. EVIDENCE: A sample of care records was looked at as part of the inspection. This showed that: • A range of care plans has been devised for each person covering such areas as personal hygiene, mobility and mental health. Care plans identify each person’s assessed needs, what the home hopes to achieve by its involvement as well as a description of the action that staff will take to meet people’s needs. Staff are knowledgeable about the content of people’s care plans and what steps they should take to meet people’s DS0000000307.V378876.R01.S.doc Version 5.2 Page 13 Kendal House • • needs. Of the six staff who returned surveys, all said they are ‘always’ or ‘usually’ given up to date information about people’s needs. A member of staff said: ‘Seniors are constantly in touch with each other giving up to date information over the phone and again in handovers. Management also report to seniors enabling care plans to be updated.’ However, people’s care plans do not cover each of the areas referred to in Standard 3 of the National Minimum Standards. Also, not all care plans have been signed or dated; Arrangements are in place to meet people’s healthcare needs. Service users said that they have been registered with a local GP and staff arrange for visits to take place if they become unwell. One service user said that the home ‘always’ ensures that they receive regular chiropody, optical and dental care. Another service user said that ‘my healthcare needs are well met and I am very satisfied.’ Staff keep good notes of any healthcare intervention that takes place. People’s weight is generally checked every month although there were some exceptions. Where people have identified healthcare needs, support plans are put in place. For example, a support plan has been devised for one service user with Diabetes. The support plan has been reviewed each month; The home has carried out preventative healthcare risk assessments to help keep people safe. For example, in the care records checked, a falls risk assessment has been completed for each person. However, a recognised risk assessment tool is not being used. Preventative pressure skin assessments have not been carried out. However, there are no service users with active pressure sores and staff are very clear about the action they would take if someone started to develop red areas or breaks in their skin. Of the six service users that returned surveys, all said that they receive the care and support they need. A member of staff said ‘we are given information about residents’ needs and any changes that take place.’ A healthcare professional said ‘I am always shown to patients’ rooms to deliver care. A member of staff is always in attendance. The home delivers a high standard of care and always respects patients’ needs.’ The home has a medication policy that staff are expected to follow. All medication is kept in a locked cabinet. Staff administer medication in a safe and professional manner. Controlled drugs are administered when required. Although a satisfactory record of the administration of controlled medicines is kept, a standardised controlled drugs register is not in use. The home’s medication records are generally good. All staff administering medication have received training. However, a written assessment of staff’s continuing competency to administer medication is not presently carried out. The providers and manager agreed to carry out competency assessments and purchase a controlled drugs register following the inspection. Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 14 No requirements or recommendations were made following a recent pharmacy inspection of the home’s medication arrangements. The Commission has not been notified of any mis-administrations of medication. Staff are knowledgeable about the steps they should take to respect people’s dignity and privacy. For example, staff are polite and courteous when communicating with service users. Staff consult service users about their needs in a quiet manner ensuring that personal matters are treated confidentially. During the inspection, staff supported one service user to their bedroom so that their GP could treat them in private. A member of staff supported another person to use the toilet ensuring that the door was kept closed. People using the service said that staff are always respectful. They could not think of any improvements that staff could make in this area. Staff spoke clearly about the standard of care that the providers and manager expect them to adhere to. They said that the manager places a lot of importance on ensuring that people are treated with respect and dignity. Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 15 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): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People experience a lifestyle at Kendal House that matches their expectations and preferences, and satisfies their social, religious and recreational needs. This also helps people to live stimulating and fulfilling lives. EVIDENCE: Kendal House has devised a planner which shows what activities are provided and on what days. Service users are able to engage in a range of activities such as armchair exercises, games, musical sessions and quizzes. Outside entertainers also visit the home on a regular basis. A service user said that religious ministers visit the home every month or more often if needed. On the day of the inspection, staff encouraged and supported service users to participate in a general knowledge quiz. The session was well received and people seemed to really enjoy the occasion. People said that they have opportunities to comment on what activities and entertainment are provided Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 16 within Kendal House. Photographs and displays of previous events are displayed in communal areas and act as a point of conversation. A member of staff said ‘I arranged for a client to be escorted to church meetings on Wednesday evenings. Also this client likes to mix with other people of their own age. So I got information for this client to attend an over 60’s club. An occupational therapist was involved as the client wished to go out independently.’ A social work professional said: ‘Staff regularly accompany my client for walks and regular activities are held.’ Of the six service users who returned surveys all said that the home provides enough activities for them to join in. One person said ‘there are activities for us to join in. I join in everything and I like the entertainers.’ People are supported to maintain links and relationships with the important people in their lives. Visitors are warmly welcomed into the home and made to feel comfortable. People using the service said that they did not know of any restrictions placed upon families and friends visiting the home. However, it was identified that care plans promoting continued contact with families and friends have not been devised. Kendal House provides a four-week menu, which includes seasonal variations. People are encouraged to put forward any ideas that they might have about new meals they would like to see on the menus. The inspector joined people for their lunch meal, which was tasty, nutritious and nicely presented. The meal was pleasantly served by courteous staff that allowed people the time they needed to eat their meals. The dining areas are nicely decorated and provide a pleasant area within which people can eat their meals. Special diets are catered for depending on the needs of the person concerned. Fresh fruit is available and beverages are provided at regular intervals throughout the day. Of the six service users who returned surveys, all said that they enjoy the food served at the home. People said that they receive enough to eat and drink. They also said that portion sizes are good and alternatives are always available if you do not like the main meal. Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 17 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): 18 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for keeping people safe are good and people using the service can be confident that staff will know what actions should be taken to keep them safe. Service users and their families can also be confident that their complaints will be listed to, taken seriously and acted upon. EVIDENCE: Previous inspections have confirmed that the provider has a suitable complaints procedure. The majority of people using the service who returned surveys said they have been told how to make a complaint. People said that they would feel comfortable raising concerns with either the providers or the manager. Neither the home nor the Commission has received any complaints since the last inspection. Of the six service users that returned surveys, all said that staff listen to and act upon what they say. People also said: ‘If I had any complaints, I would definitely talk to the staff. I was showed the complaints procedure which is on the main notice board. It was fully explained.’ ‘Staff listen to me and act upon what I say.’ Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 18 The provider has devised a safeguarding policy to help people keep safe. The policy has not yet been updated to reflect the manager and providers’ duties and responsibilities under the Mental Capacity Act and following the introduction of the Independent Safeguarding Authority. The Commission has been notified of one safeguarding concern, which was dealt with under the local authority’s safeguarding protocols. The providers and manager cooperated fully with the local safeguarding team and the concerns raised were unsubstantiated. People using the service said that they feel safe living at the home and trust the staff that care for them. The manager was very clear about the action she and her senior team would take to protect the people in their care. All staff have completed safeguarding training. Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 19 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): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are able to benefit from living in a well-maintained home that has been adapted to meet their needs. EVIDENCE: The premises are safe, well-maintained, comfortable, clean and odour free. The home’s décor, furniture and fittings are of a good standard. Immediate action is taken to address health and safety concerns. The home has been adapted to meet the needs of people living at Kendal House. For example, assisted bathing facilities and independence aids are provided throughout the home. Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 20 Bedrooms are kept clean and homely and have been personalised to reflect people’s individual preferences. Single room accommodation is available with 12 rooms having en-suite facilities. Bathrooms, toilets, the laundry and kitchen are kept clean and hygienic. No concerns about the premises were identified. The home has well maintained garden areas that provide people with safe access to attractive outdoor spaces. The provider has devised an infection control policy which staff are expected to follow. All staff have received training in the control of infection. No infection control concerns were identified during this inspection. Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 21 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. Staffing levels are good and staff are provided with the training they need to carry out their job to a good standard. This means that people using the service can be confident that their care will be delivered by competent and professional staff that have been trained to do their job. EVIDENCE: There are rotas that show which staff are on duty and at what times. The staff team consists of the manager, senior carers and care staff. The rotas show that for up to 24 service users there is always a minimum of three staff on duty between 8 am and 8 pm. In addition, the providers work at the home on a daily basis. Although the manager’s hours are supernumerary to care rota, staff said that she is always around to provide advice and guidance. An activities co-ordinator, catering and domestic staff are also provided each day Two waking night staff are provided from 8pm to 8am. People living at Kendal House spoke very well of the staff that support them and said that staffing levels at the home are sufficient to meet their needs. Of the six staff who returned surveys, all said that there are ‘always’ enough staff on duty to meet people’s individual needs. A member of staff said: ‘There are enough staff, and in cases where our residents have to go to appointments, extra staff are Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 22 generally brought in so that the staff on the floor can continue to be able to meet residents’ needs.’ Over 50 of the staff team have obtained a National Vocational Qualification at Levels 2 and 3 and a further three staff are in the process of doing so. A range of pre-employment checks are carried out before staff can commence work at the service. For example, staff are required to complete an application form and attend a selection interview. A Criminal Records Bureau disclosure check has been obtained for each member of staff. However, a full employment history has not been obtained for some of the staff whose personnel records were looked at. Following the inspection, the providers immediately updated their application form to ensure that all prospective employees provide a full employment history. Also, there was no documentary evidence that the identity of one member of staff had been verified. Of the six staff that returned surveys, all said that the provider had carried out employment checks such as obtaining a Criminal Records Bureau disclosure before they started work at the home. Staff said that they received an in-house induction which focussed on people’s support needs, the home’s policies and procedures and day to day routines at Kendal House. A standardised Induction and Foundation Training Record is used to provide evidence that staff have completed the ‘Skills for Care’ induction standards. However, some of those looked at had not been fully completed. The manager agreed to look at this immediately. Of the six staff who returned surveys, all said that their induction covered everything that they needed to know to do the job. A member of staff said: ‘My induction was very good and I was told everything I needed to know about my job.’ Another staff member said: ‘The manager spent a great deal of time with me during my induction and didn’t hesitate to go over anything with me that I was unsure about. I feel the induction was thorough.’ There are opportunities for staff to complete and update their training in key areas. For example, in the sample of staff files examined, there was documentary evidence that all had completed training in first aid, fire safety and health and safety. Staff also complete training that is more geared towards meeting the needs of older people. For example, senior staff have completed Mental Capacity Act training awareness. The manager has arranged for staff to receive additional support in this area and has prepared authorisation forms which will enable a referral for an assessment to be made as promptly as possible. Some staff have received training in Dementia care, nutritional health and caring for people with Diabetes. Of the six staff that returned surveys, all said that their training was relevant to their role, helped them to understand the needs of people using the service and kept them up to date with new ways of working. One member of staff said: ‘I do plenty of training to cover all aspects of care and training is ongoing.’ Another person Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 23 said: ‘Our manager is always looking for training for us to do. I recently did training in the Mental Capacity Act which was very interesting.’ Staff also said that they felt they had the right support, experience, and knowledge to meet the different needs of people using the service. Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 24 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): 31, 32, 33, 35 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Satisfactory arrangements are in place to manage the home and ensure that the building is safe and well maintained. This means that people are able to benefit from the ethos, leadership and management approach of the home, which ensures that their health and well-being is promoted and protected. EVIDENCE: The manager, Angela Oliver, has worked in the home for twenty years and has managed Kendal House for fourteen years. She has obtained a NVQ at Level 4 in Care as well as the Registered Manager’s Award. Ms Oliver displays good Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 25 management skills and was observed to provide staff with good support and guidance throughout the inspection. Staff are clear about the standards of care they are expected to deliver and support arrangements are in place that enable this to happen. A member of staff who returned a survey said: ‘The manager is always there whenever I need her and I have regular reviews.’ The manager is well supported by the providers who are always on hand to offer advice. Wherever possible, people using the service have their own bank accounts, some of which are managed by family members. Secure lockable drawers are available in each bedroom. Some people choose to keep their valuables in the home’s safeguarding facilities. Where the home helps people to manage their money, receipts and records are kept to safeguard their financial interests. Staff receive formal supervision on a regular basis in line with the National Minimum Standards. Staff interviewed said that they meet regularly with their manager and feel well supported. Arrangements are in place to ensure that people’s health and safety is treated seriously and the premises are safe and well maintained. For example, the providers have devised a range of health and safety policies and procedures that staff are expected to follow. Kendal House has an up to date gas safety certificate and the home’s electrical equipment has recently been checked. A controlled waste contract is in place ensuring that all hazardous waste is appropriately disposed of. The home’s nurse call system has recently been serviced. A range of fire prevention checks are carried out and the home’s fire risk assessment has been reviewed within the previous 12 months. Certificates demonstrating that the fire alarm system, fire extinguishers and emergency lighting have been serviced are available. Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 26 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 X 3 3 X 3 Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 27 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 OP29 Regulation Schedule 2 Timescale for action Ensure that all staff employed 01/07/09 post April 2002 have provided a full employment history. This will help to ensure that only suitable staff are employed at the home. Requirement 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 OP3 Good Practice Recommendations Ensure that: • • 2. OP8 People’s care plans cover each of the areas referred to in Standard 3 of the National Minimum Standards; Each person’s care plans are signed and dated. Use a recognised assessment tool to carry out falls and DS0000000307.V378876.R01.S.doc Version 5.2 Page 28 Kendal House pressure sore prevention risk assessments. 3. OP9 Purchase a standardised controlled drugs register for use within the home. Regularly assess staff’s competency to administer medication. Staff training files should contain a record of any assessment carried out. 4. OP13 Devise care plans that provide staff with clear guidance on how to promote people’s continued contact with their families and friends. Review and update Kendal House’s safeguarding policy and procedures to ensure that they reflect the manager and providers’ responsibilities and duties under the Mental Capacity Act, and following the introduction of the Independent Safeguarding Authority. 5. OP18 Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 29 Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 61 61 61 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.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 Kendal House DS0000000307.V378876.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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