Care Home: Kendall House

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What the care home does well Kendall House is a well-run home offering a good standard of care; the manager and staff endeavour to provide a good quality of life for those people who live at the home. The overall impression following the visit was that the individuals living at the home are happy, settled and secure and the staff have a good rapport with them. Some of the staff members have known those who live at the home for many years and have an in depth knowledge and understanding of their needs, this contributes to the wellbeing of individuals who live at Kendall House. People who live at Kendall House are supported through individualised care planning. Staff are provided with comprehensive information in order to meet their assessed needs. Those living at Kendall House all have individual support needs and these are well managed at the home. People are supported well with full access to specialist services such as Psychology, hospital care and access to the community learning disabilities team.Those who live at Kendall House are well supported by staff to live a varied and fulfilling life in and out of the home. It was clear that relationships between those who live and work at the home are good. People told us `I like it here` and named individual staff members who they got on well with. Those who live at Kendall House benefit from a competent team who have a good understanding of individuals support needs. The home has a structured admission process based on the homes ability to meet the assessed needs of individuals. What has improved since the last inspection? There were two recommendations made during our last visit to the service, these were to fine-tune the care service provided to residents. These related to the recording of the daily records and the frequency of resident meetings. Both recommendations had been met. CARE HOME ADULTS 18-65 Kendall House 15 Wesley Lane Warmley South Glos BS30 8BU Lead Inspector Odette Coveney Unannounced Inspection 23rd June 2008 09:00 Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 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 Kendall House DS0000003370.V359059.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 Adults 18-65. 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. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kendall House Address 15 Wesley Lane Warmley South Glos BS30 8BU 0117 9602508 0117 9566050 mclarke@themanorhouse.org 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) Mrs Marilyn Joan Clarke Mrs Julie Ann Smith Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 8 persons aged 18 - 64 years requiring personal care only May accommodate one named person with learning disabilities who has dementia 27th June 2006 Date of last inspection Brief Description of the Service: Kendall House is located in the village of Warmley approximately five miles from the centre of Bristol. It is in a semi rural location close to Warmley Common. There are shops and other community amenities within a mile of the home. The home is registered with the Commission for Social Care Inspection to provide accommodation and personal care to eight persons with learning disabilities aged between 18 and 64 years. Kendall House is one of four homes within the Manor House Organisation that provide for adults with learning disabilities and one provides respite for children with a learning disability. The accommodation in Kendall House is on two floors. There is one shared bedroom. There is a spacious patio area accessed from the lounge area, which leads to the garden. The service values for the home are concerned with dignity, independence, and participation, valuing people, equality, rights and working together. The fees for the service range from £550 to £1200. Kendall House DS0000003370.V359059.R01.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 2 stars. This means the people who use this service experience Good quality outcomes. This visit to Kendall House was unannounced and took place over one day, we also returned to the home the following evening in order to spend time and talk with those who live at the home. During our visit time was spent examining a number of records including care documentation, health records and health and safety documentation. Staff recruitment and training records were also reviewed. Prior to the site visit we received from the home a completed an annual quality assurance assessment (AQAA). The annual quality assurance assessment is a new process that is being used for all regulated services from April 2007. 10 Comment cards were received prior to our visit to the home, 3 of these were from relatives of those who live at the home, 5 were from individual’s who live at the home, the 2 other comment cards were from visiting health/social care professionals who visit individuals at the home. Comments made were reviewed during the visit and these, maintaining individual’s confidentiality, were shared with the registered manager and have been incorporated within this inspection report. What the service does well: Kendall House is a well-run home offering a good standard of care; the manager and staff endeavour to provide a good quality of life for those people who live at the home. The overall impression following the visit was that the individuals living at the home are happy, settled and secure and the staff have a good rapport with them. Some of the staff members have known those who live at the home for many years and have an in depth knowledge and understanding of their needs, this contributes to the wellbeing of individuals who live at Kendall House. People who live at Kendall House are supported through individualised care planning. Staff are provided with comprehensive information in order to meet their assessed needs. Those living at Kendall House all have individual support needs and these are well managed at the home. People are supported well with full access to specialist services such as Psychology, hospital care and access to the community learning disabilities team. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 6 Those who live at Kendall House are well supported by staff to live a varied and fulfilling life in and out of the home. It was clear that relationships between those who live and work at the home are good. People told us ‘I like it here’ and named individual staff members who they got on well with. Those who live at Kendall House benefit from a competent team who have a good understanding of individuals support needs. The home has a structured admission process based on the homes ability to meet the assessed needs of individuals. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Information is in place about the facilities and services provided at Kendall House. Individual’s aspirations and needs are assessed prior to making a decision about moving into the home. Clear contractual arrangements are in place outlining individuals’ rights and responsibilities EVIDENCE: Kendall House is registered with the Commission to accommodate 8 people, there are no vacancies. We did not fully review the homes statement of purpose or service users guide during this visit. The manager confirmed that there have been no significant changes to these documents and that these are kept under review to ensure that the information contained within them is correct. During our last visit to the service undertaken on 26th June 2006 we reported that these documents contained all of the required information in order that those looking for a Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 9 placement at Kendall House have all of the information they needed before making a decision about moving into the home. Since our last visit to the home two new people have moved in, we spoke with these people and the manager to discuss how this had went. We also fully reviewed the care records and other associated documents for these people. These showed evidence of pre-admission assessments to enable staff to develop personalised care plans of individuals and these record how the needs were to be met. We saw that there is a clear process to ensure that the service is able to meet the assessed care needs of prospective people moving to the home. There is an admission procedure, which is included in the statement of purpose and full assessments of needs are undertaken. Records evidenced that both people were supported well with their move into the home, the process for admission was a gradual one and was tailored to each individuals needs. Both people visited the home at various times of the day, had meals at the home and joined in with social events and they also had the opportunity to have an overnight stay at the home. We also saw in minutes of residents meetings that those people who already live at Kendall House had been consulted about the prospect of new people coming into the home and their views had been taken into consideration. We spoke with the two people recently admitted into the home who told us that they had settled well at the home and that the staff and other people who lived at the home had made them feel very welcome. One person said ‘the staff here are lovely and I have made friends here’. We decided to review the contracts of ‘terms and conditions of the placement’ for some of the people who live at the home. Not all of these documents were on site at the home as they were in the process of being updated. When we returned to the home the following evening these documents had been reviewed and were in place. Those living at the home have their own copy of the contract and have written information about the rights and responsibilities of the responsible provider and of the service, which they are provided with. We did note that not all parties involved had signed these documents. It is recommended that this be done in order to evidence that all have been consulted and have been part of the process. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who live at Kendall House are supported to make their own decisions about their lives with assistance where needed. All individuals have a plan of care in place that has been developed with them. Individuals are supported and encouraged to take risks as part of their independent lifestyle, some minor improvements could be made to ensure risks have been fully evaluated. EVIDENCE: Since our last visit to Kendall House the home have totally revised the process for recording information about those who live at the service. Each file is broken down into seven sections: these cover pre admission information, religious and cultural preferences, care and support management, person centred planning, health support service, ‘where I go in the day’, social leisure and family details and information to support individuals with their finances. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 11 During our visit we reviewed three care files for people who live at Kendall House, these showed evidence of pre-admission assessments these enable staff to develop personalised care plans for people and recorded how needs were to be met. The care plans were detailed and explicit. Daily reports contained entries of what, when and how care was provided. Information recorded on care documentation corresponded with information given from those who live at the home, staff and relatives about the level and individualised levels of support that people received. It was clear that the assistance provided was flexible and tailored to individuals identified and requested needs. Individuals had been involved in the process of gathering information about how they wanted to be supported in their life and their views and wishes had been recorded. During our last visit to the home we recommended that the home review the recording of daily records in a central book in order to ensure that peoples confidentiality is maintained. We viewed this area of recording at the home and saw that the home now maintain individual records for each person, these are loose leaf and can then be transferred to individuals care files. Regular consultations take place with those who live at the home; these are both informal on a day to day basis and also formal discussion in meetings, which have been recorded. We saw that people have been asked for their opinion on areas that affect their life, that this had been listened to and acted upon appropriately. Individuals have been involved with their own personal review meetings and expressed their views. Those living at Kendall House said that they were happy at the home and appeared well cared for. A number of comment cards were received from visiting professionals and relatives of those living at the home and one person said that; ‘individual’s needs were being well met by a caring and supportive staff team’. Relationships between individuals and staff are well established and effective methods of communication both verbal and non-verbal have been developed. When we visited during the evening staff were observed going about their duties in a friendly and calm manner and responding to those living at the home in a familiar style. There was friendly banter between individuals and the staff which was appropriate. Those who live at Kendall House are supported to take risks in their daily lives by staff. There were detailed written risk assessments that were linked to the care plan. They demonstrated actions are taken to ensure the home is safe for those who live and work at the home. Risk assessments also demonstrated people are encouraged to live an independent and fulfilling life and take part in varying activities. We saw within a care management assessment that one person has been a subject of strategy meetings in order to protect them as a Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 12 vulnerable adult. In order to ensure that this person and staff are fully protected it is required that a risk assessment to be completed by the home in order to fully evaluate the possibility of false allegations being made. We also saw that that home have a risk assessment in place in respect of their forthcoming holiday, although social activities were covered it is required that this assessment is reviewed and additional areas of risk such as security of medication, accident/injury and personal safety are covered and recorded. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17. 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 the social and recreational needs of individuals are good and there are opportunities for those living at Kendall House to maintain links with family, friends and the local community. The home’s practice and routines are flexible and enable individuals to exercise choice and have control over their lives. EVIDENCE: Staff enable those who live at the home to have opportunities to maintain and develop social, emotional, communication and independent living skills. On the day of the visit those who live at Kendall House were busy partaking in activities of their choosing and were being supported by staff at the home. Activities seen within records showed that individuals are involved and supported on a regular basis to participate in activities of their choice such as Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 14 attending church, visiting the local community centre, visiting the market, going swimming, shopping and visiting family. People living at the home told us about their interests and hobbies and how they are supported with this. On the evening we visited people showed us clothes they had recently bought and told us about there forthcoming holiday to which they were looking forward to. Another person showed us photographs of them participating at their drama group and they told us how much they enjoy this area of their life. During our evening we visit those living at the home were just finishing their evening meal, and saw different meals being offered. Some individuals go shopping with staff and choose food whilst out. The records show that people eat a balanced diet with a good variety of meals on offer. We saw that those who live at the home are regularly asked at meetings about the quality, choice and quantity of the food. Individual’s views are taken into consideration when menu planning takes place at the home, we also saw that individuals likes and dislikes are recorded. People living at the home have a key to their own room and also a key to the main front door. Family and friends are welcomed to the home and those who live at Kendall House can choose whom they wish to see; they can see visitors in the communal areas or for privacy in their individual rooms. Comment cards were received from relatives of those who live at the home all confirmed that visitors are welcomed at the home at any time, that they are kept informed of important matters affecting their relative and that they are satisfied with the overall care provided at the home. Other recorded comments included ‘I think the all round general care is excellent and all the care staff do their utmost to make the quality of life as good as possible for the residents’, ‘Staff do a wonderful job’. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff provide appropriate personal support care in a sensitive manner to maintain each persons health and well being. Appropriate arrangements are in place for individuals to access primary and specialist healthcare services if needed. Staff at the home properly manage and administer medication. EVIDENCE: The health needs of individual’s are well met with evidence of good multi disciplinary working taking place on a regular basis. All of those living at the home are registered with a general practitioner; evidence was in care records to confirm that individuals are supported with their primary healthcare needs such as optician, dentist and chiropody and that specialist advice is obtained when needed. We saw that clear information and protocols were in place to support individuals in specialist areas of their care such as continence support, oncology and support from the community learning disabilities team and psychology. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 16 A comment card received by us from a visiting healthcare professional who visits people who live at the home reported ‘I have been extremely impressed by their high standards of care and personal attention given to these clients, great professionalism, and wonderful patience, comments received from other colleagues are also very positive’. Care records contained clear information on how individuals wish to be supported with their personal care and provided guidance for staff to ensure continuity of care. The home’s medication storage systems were in good order. A check was done on some of the medication in the storage cupboard and this was found to be all correct and accounted for. Records for the administration and disposal of medication were in place and had been well maintained. There has been an outstanding requirement this was for the home to develop a policy on self-medicating. The manager said that there are no people living at the home who self administer their own medication. We saw that individuals are supported in this area appropriately with information recorded on individuals care plan and risk assessments outlining the level of support they require. Some discussion took place with the manager about how individuals should be supported and encouraged to have a level of independence in this area and how barriers could be overcome, we look forward to reviewing progress in this area at our next visit to the service. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those living at the home are protected from the potential of abuse and complaints are dealt with appropriately due to staff training and understanding in this area. Clear policies and procedures are in place. EVIDENCE: The home has a procedure, which outlines the steps to take if there are any complaints. People living at the home are aware of how to contact the Commission for Social Care Inspection (CSCI). A complaints record is kept and any complaint are recorded. No complaints have been received either by the home or to CSCI. We saw that all the people living at the home have been given a pictorial copy of the organisation’s complaints procedures, which include the contact details of the Commission. We saw that during a staff meeting held at the home in April 2008 an area of discussion included the protection of vulnerable people. Staff discussed the homes ‘whistle blowing’ policy, what it involved and staff role and responsibility in this area. The minutes of the meeting demonstrated that staff have a sound understanding in this area. The Annual Quality Assurance Assessment completed by the home told us that the home has a member of staff who is a protection of vulnerable adults trainer. All living at Kendall House are encouraged to air their views, and both care staff and the manager are keen to hear any suggestion from people about how Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 18 the service could be improved. We saw that the minutes of residents meetings are produced in both written and pictorial format. One of the people we spoke with who lives at Kendall House told us that they were happy at the home and that if they had any complaints they would “go straight to speak with the manager”. Due to peoples varied communication, both the staff and families advocate for individuals and care files held well documented information regarding how those who live at Kendall House communicate and express their emotions. The home has good relationships and ongoing communication with families. This helps ensure that staff would be told of any concerns that families may have regarding their relatives care. Some discussion took place with the manager of the home about their responsibility in respect of the protection of vulnerable people, it was clear that the manager is very aware of their role in this area and is committed in ensuring the safety of those living at the home. Kendall House has clear policies and procedures in this area. There are staff working at the home that have either achieved or are undertaking a National Vocational Qualification in Care, (Health and Social Care, Levels 2 & 3) and this has a core unit that incorporates adult protection and staff responsibility should they have any suspicions or concerns. It was further noted when reviewing staff training files that staff have completed training in the protection of vulnerable adults. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those living at Kendall House live in a homely, comfortable and safe environment. EVIDENCE: There have been no changes in the services and facilities provided at the home since our previous visit. The location and layout of the home is suitable for its intended purpose. Kendall House is furnished to a good standard. The home is situated in Warmley it is within walking distance to a local shop and post office; the home blends in well with the local community. At the time of our visit all areas seen were clean, tidy and odour free. All of those living at the home have access to their personal space. There is a comfortable lounge with patio doors that lead out to the large, well tended garden. There is also a kitchen/dining area and those who live at the home were seen to be making good use of this area during our visit. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 20 Since our last visit to the service there have been a number of improvements to the environment; 6 bedrooms have been redecorated, a bathroom has been refurbished in order to make it more accessible to those with mobility difficulties, some floorings have been replaced and the outside of the house had been repainted. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment procedures are robust. Staff are enthusiastic, have a good understanding of the peoples’ needs and work positively to improve their quality of life. Those living at Kendall House can be confident that staff are effective and competent and have been provided with the training needed to fulfil their role. EVIDENCE: The manager and staff were able to demonstrate that they had developed good relationships with those who live at the home and have a sound understanding of their needs, wishes and aspirations. These are well recorded in individual’s records. Individuals we spoke with indicated that relationships with staff were good, one person told us that they got on really well with staff, they listened and were good at their job. Staffing provision appeared to be consistent with levels and skills needed due to assessed care needs of the individual’s. The staff team have a varied range of knowledge and skills, they were observed by us during the visit interacting Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 22 with the people living in the home and each other in an informal, friendly and respectful manner We reviewed the recruitment and selection processes these demonstrated a robust procedure is in place. All the required information was available, including Criminal Record Bureau checks, protection of vulnerable adults checks and 2 written references, ensuring as far as possible only suitable staff are employed. Regular staff meetings and individual supervision sessions take place and addressed the principles and values of the home, staff performance and training and development needs, as well as day-to-day support issues. During our visit a sample of staff training files were examined, including one for a newly appointed staff member. Since our last visit the home have been developing continual personal development folders. Information we saw showed us that staff have undertaken core skills training such as fire safety, manual handling, first aid as well as specialist training when required such as dementia awareness. The home has a satisfactory induction and orientation programme, staff work through the comprehensive skills for care induction process. Records of such are kept. There is a commitment from the organisation in ensuring that the home has 100 of the staff team obtaining a National Vocational Qualification (NVQ) in care. The majority of the staff have now commenced or are part way through training. Staff supervision and appraisal processes are in place. There are regular team and management review meetings meetings in order to ensure effective service delivery, continuity of service and effective communication. We spoke with a staff member who said they are very happy within their role at the home and said that they felt well supported by the manager. This member of staff was fully conversant with the support that individuals require at the home and gave sound examples of how individuals are given choices and how their rights are promoted and how individuals are treated as adults Comments received from staff prior to our visit indicated that staff feel they have the right support and training in order to meet the different needs of people using the service. Comments included ‘we have quality staff, we provide customised care and strive for continual improvement’ another said, ‘Our home is very special and almost an extension of our own family lives, we involve those who live at the home in everything we do’. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who live at Kendall House benefit from a well run home that is managed with a clear sense of direction. There are formal quality monitoring systems in place in order to measure the aims and objectives of the home. There are procedures and protocols in place in order to ensure the health, safety and welfare of those who live and work at the home. EVIDENCE: The manager Julie Smith has many years experience of working with people with learning disabilities she has achieved a Registered Managers Award in Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 24 care management and is committed to providing a good service for those who live at Kendall House, to ensure that they have positive outcomes and are supported to achieve aims and goals they have set for themselves with support from others. The manager is part of the organisations senior management team who meet six times per year for planning strategy and performance monitoring. Julie Smith cooperated with us fully during this visit and was able to locate all necessary information and documents easily. This evidences that the home has good systems in place and is well run. The Responsible Individual for the home visits each month. These visits are used to ensure the home is being managed within the Organisation’s policies and procedures and include reviewing areas such as each person’s care documents; the homes’ financial records as well as those monies being held for safe keeping; issues relating to the management of the home and staff training and supervision. A report of these visits had been sent regularly to the Commission. The manager has a very “hands-on” approach and is very involved and aware of the needs of those who live and work at the home. Both meetings for residents and staff are held on a regular basis and there was evidence that everyone is encouraged to make suggestions about how the home is run and what happens, staff spoken with also confirmed this. From talking with staff it was evident that they felt supported in their role by the manager. There are clear equal opportunities policies within the home and all staff have access to copies of these. Staff meetings are held regularly and there are also other strategies for enabling staff, clients and other stakeholders to voice concerns and to affect the way in which service is delivered. These included staff supervision, review meetings, quality assurance, and an open and approachable management approach. It was also reported that the responsible individual Mrs Marylyn Clarke visits the home on a regular basis, spends time with those who live at the home, staff and the manager and oversees the service provided at the home. Staff spoken with said that she is approachable and committed in ensuring that the rights and choices of those living at the home are supported. Prior to the site visit we received from the home a completed an annual quality assurance assessment (AQAA). The annual quality assurance assessment is a new process that is being used for all regulated services from April 2007. This had been fully completed by the home and recorded areas of improvement over the past twelve months and identified areas of future improvement plans to ensure positive outcomes for those who live and work at the home. The daily records, care plans, healthcare and staffing records were viewed at this visit, and it was found that records are well maintained. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 25 The home has in place policies and procedures in respect of a service being provided for young adults. Policies in place included: confidentiality, equal opportunities, sexuality and relationships. A number of the policies and processes in place within the home link into the NVQ award being undertaken by staff. The principles and values include treating people as individuals with dignity and respect with rights and choices. During our visit staff were polite and valued people as individuals and adults. We discussed with the manager the significance of the Mental Capacity Act and how this should be considered when reviewing and updating polices and procedures. This in order to ensure they are line with current legislation. The home have ensured that The Commission are notified of incidents that affect the wellbeing of those living at the home and we have found that incidents had been dealt with appropriately ensuring the safety and wellbeing of those involved. There are health and safety procedures in place for those who live and work at the home to follow; records identified that are procedures in place to monitor all aspects of the health and safety of the home including audits being carried out. The fire logbook record showed that the range of required fire safety checks were being carried out and were up to date helping to ensure the safety of people inside the building is maintained. All staff have attended both fire training and regular fire drills. During our last visit to the service we recommended that the home should seek the views of those who live at the home on how frequent residents meetings should be held. During this visit we reviewed a number of minutes of meetings and saw that each person was asked for their opinion, Individuals were actively encouraged to give their views on all area, which affected living with others in a care home. Within a comment card received by us prior to our visiting the home a relative told us ‘the home does what it says, it cares. The residents are all looked after well and are treated as individuals with individual needs’. Kendall House DS0000003370.V359059.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 Adults 18-65 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 3 3 X Kendall House DS0000003370.V359059.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 YA9 Regulation 4 (c) Requirement A risk assessment to be completed in order to fully evaluate the possibility of false allegations being made. The current risk assessment in respect of supporting residents whilst on holiday must be reviewed and expanded upon in order that potential areas of risk are evaluated. Timescale for action 23/08/08 2. YA9 4 (c) 23/08/08 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. 2. Refer to Standard YA5 YA40 Good Practice Recommendations Contracts and ‘terms and conditions’ of the placement should be signed by all appropriate parties. When policies and procedures are reviewed they should take into account current legislation. Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Kendall House DS0000003370.V359059.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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