Care Home: Kenwood

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• Henry Nihill House
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What the care home does well Residents we met appeared clean and were appropriately dressed. All stated that they were satisfied with the care provided. The home is clean and well furnished. The garden is well maintained. Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 There is a varied range of social and therapeutic activities for residents. The activities organiser is able to provide one to one sessions for certain residents who need them. Information leaflets on how to cope with the hot weather were on display along the corridor. All bedrooms inspected had a jug of water by the bedside. The home appointed a staff member in March of this year as "a Dignity in Care Champion". We were informed that her role is to promote dignity and compassion in care in the home. This staff member would observe staff interaction with residents and ensure that staff treat all residents with respect and dignity. Staff are well trained and they are closely supervised. We note that staff were attentive and respectful towards residents. What has improved since the last inspection? Improvements have been made in the care arrangements. Diligence had been exercised in the care of pressure sores. Monitoring charts are appropriately signed and care plans are in place. Up to date healthcare appointment records are kept. The arrangements for the administration, ordering, storage and disposal of medication were found to be well managed. Regular audits had been carried out. The staffing arrangements were satisfactory and a review of staffing levels had been carried out to ensure that the care needs of residents are met. Staff were closely supervised and detailed records had been kept. We note that residents have been addressed appropriately by staff and they inform us that they had been treated with respect and dignity. Staff were noted to be adhering to be wearing protective clothing when assisting residents with their meals. The home`s records were up to date and easily accessible. The fire door guards in place had been tested weekly and were in working condition. Night fire drills had been carried out. What the care home could do better: Improvements must be made in the area of adult protection. All allegations of abuse must be reported promptly to Social Services and The Care Quality Commission. This is to ensure the protection of residents. The home must have a written procedure for the use of staff who only have a pova disclosure and are in the process of receiving their CRB disclosures. ThisKenwoodDS0000010457.V376139.R01.S.docVersion 5.2is to provide the necessary guidance on working arrangements and to ensure the protection of residents. Significant incidents, including theft of money must be notified to The Care Quality Commission. This is to ensure the registration authority is kept informed and for the protection of residents. Excess furniture must not be left near the fire exits. This is to ensure that the safety of residents and staff in the event of a fire. The procedure for using bed rails should be reviewed to ensure that the views of professionals involved with residents concerned are noted. This is to ensure that relevant information is obtained and appropriate care and safeguards are in place to protect residents. Key inspection report CARE HOMES FOR OLDER PEOPLE Kenwood 30-32 Alexandra Grove Finchley London N12 8HG Lead Inspector Daniel Lim Key Unannounced Inspection 2ndJuly 2009 09:00 DS0000010457.V376139.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kenwood Address 30-32 Alexandra Grove Finchley London N12 8HG 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) 020 8445 5112 020 8343 7992 New Century Care (Finchley) Limited Care Home 32 Category(ies) of Dementia (14), Old age, not falling within any registration, with number other category (32) of places Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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 2. Dementia - Code DE (maximum number of places: 14) The maximum number of service users who can be accommodated is: 32 6th August 2008 Date of last inspection Brief Description of the Service: Kenwood Nursing Home is a care home which has been registered to provide care for a maximum of thirty two older adults with nursing needs. The home may accommodate up to a maximum of fourteen older adults with dementia. It is owned and managed by New Century Care (Finchley) Limited. The parent company also owns and runs other care homes in this country. The home has a mission statement, which says that it aims to ‘provide good quality accommodation, nursing and personal care for vulnerable elderly people, who as a result of loneliness, physical disability or illness are seeking an understanding and caring environment. The home is a large three storey detached house. There are 22 single bedrooms and 5 shared bedrooms. All the bedrooms have en-suite facilities. Residents’ bedrooms are located on both floors. The main office, kitchen, laundry and communal dining room are on the ground floor. There is a lounge on each floor. A small activity room is located on the first floor. The third floor has a staff room and storeroom. There are two lifts between the ground and Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 5 first floors. There is a small parking area at the front of the building and a large garden at the rear with wheelchair access. The home is situated in a residential area and close to shops, restaurants and transport facilities located along Ballards Lane, North Finchley. Details of fees charged by the home may be obtained from the home manager. The provider must make information about the service available (including reports) to service users and other stakeholders. Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 6 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 inspection was carried out by Daniel Lim and Tom McKervey, Regulatory inspectors. The inspection started on 2 July 2009. A second visit was made on 6 July 2009 to view documents and interview staff not present during the first visit. We were assisted by the manager, Ms Susan Njeri Maruri. The Operations Manager (Ms Sue Starkey) was present during the first day and a second Operations Manager (Ms Helen Bennet) was present on the second day. This inspection took a total of eight hours to complete. Four residents and four relatives were interviewed. The impression gained was that residents were well cared for. Statutory records were examined. These included four residents’ case records, the maintenance records, accident and incident records, financial records, complaints records and fire records of the home. The premises including residents’ bedrooms, communal bathrooms, laundry, kitchen, garden and other communal areas were inspected. Six staff were interviewed regarding the care of residents and other areas associated with their work. They were noted to be knowledgeable regarding their roles and responsibilities. Staff records, including evidence of CRB and POVA disclosures, references, supervision and training records were examined. In addition, we were provided with the minutes of residents’ and staff meetings. These indicated that residents and staff had been informed of changes affecting the running of the home. The completed Annual Quality Assurance Assessment form or AQAA was previously received by CQC. Information provided in the assessment was used for this inspection. What the service does well: Residents we met appeared clean and were appropriately dressed. All stated that they were satisfied with the care provided. The home is clean and well furnished. The garden is well maintained. Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 7 There is a varied range of social and therapeutic activities for residents. The activities organiser is able to provide one to one sessions for certain residents who need them. Information leaflets on how to cope with the hot weather were on display along the corridor. All bedrooms inspected had a jug of water by the bedside. The home appointed a staff member in March of this year as “a Dignity in Care Champion”. We were informed that her role is to promote dignity and compassion in care in the home. This staff member would observe staff interaction with residents and ensure that staff treat all residents with respect and dignity. Staff are well trained and they are closely supervised. We note that staff were attentive and respectful towards residents. What has improved since the last inspection? What they could do better: Improvements must be made in the area of adult protection. All allegations of abuse must be reported promptly to Social Services and The Care Quality Commission. This is to ensure the protection of residents. The home must have a written procedure for the use of staff who only have a pova disclosure and are in the process of receiving their CRB disclosures. This Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 8 is to provide the necessary guidance on working arrangements and to ensure the protection of residents. Significant incidents, including theft of money must be notified to The Care Quality Commission. This is to ensure the registration authority is kept informed and for the protection of residents. Excess furniture must not be left near the fire exits. This is to ensure that the safety of residents and staff in the event of a fire. The procedure for using bed rails should be reviewed to ensure that the views of professionals involved with residents concerned are noted. This is to ensure that relevant information is obtained and appropriate care and safeguards are in place to protect residents. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Kenwood DS0000010457.V376139.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 Kenwood DS0000010457.V376139.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 3, 6 Admissions are not made to the home until a full needs assessment has been undertaken by the senior allocated staff. Admissions only take place if the service is confident that the needs of people to be admitted can be met. This ensures that the admissions to the home are appropriate. EVIDENCE: The home’s completed AQAA indicated that all prospective residents would be fully assessed to ensure that the home can meet the needs of individuals before their admission. The AQAA stated : Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 11 “New residents are only admitted on the basis of a full and comprehensive assessment undertaken by people trained or experienced to do so and to which the prospective resident, his/her representative and relevant professionals have been party to. For individuals referred through Care Management arrangements, the registered person obtains a summary of the care management assessment and a copy of the care plan produced for care management purposes. For individuals who are privately funded and without Care Management assessment the registered person carries out a needs assessment covering all aspects. Careful consideration is given to the assessment before agreement to admission to the home, therefore ensuring staff are qualified and skilled to meet the needs of the resident; a written letter of confirmation is sent to clarify the assessment and its outcome; although Social Services complete an assessment the home completes its own to supplement the social services assessment; information is obtained from medical staff as a contribution to the assessment process to provide a clear understanding of residents’ needs.” The pre-admission assessments which were examined by us were noted to be appropriate and comprehensive. They contained details of the personal, mental, cultural and spiritual needs of residents. Risk assessments had also been prepared for those admitted into the home. Their preferences had also been recorded. The manager informed us that the home does not provide intermediate care. Kenwood DS0000010457.V376139.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 7, 8, 9, 10 Residents living in the home have access to healthcare services in the local community. There is evidence in the case records that healthcare needs are monitored and appropriate intervention taken. The arrangements for the administration of medication were satisfactory. This ensures that residents are well cared for. EVIDENCE: The home’s AQAA stated: “Each resident has a care plan generated from comprehensive assessments which are regularly reviewed, these provide good information for the care Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 13 team to implement high quality care to meet residents needs and provides the basis for the care to be delivered; Residents care plans meet the relevant clinical guidelines produced by the relevant professional bodies concerned with the care of adults, and includes risk assessments. The care plan are reviewed by staff within the home at least once a month (or according to changing needs) and is updated to reflect changing needs and current objectives for health & personal care, and actioned. Care files are audited by the home manager and area manager. Care plans detail which actions the resident remains capable of performing and encourages independence at all times.” The sample of four residents’ case records examined by us contained detailed care plans and important risk assessments. These plans of care had been prepared in consultation with residents and their representatives and had been signed by them. We note that they were up to date and had been reviewed monthly. The care plans of a resident who was at risk of pressure sores was examined in detail. We noted that the risk assessments and care plans were appropriate and comprehensive and contained guidance to staff on how this resident is to be specifically cared for. The pressure area monitoring charts of this resident were examined. These had been appropriately signed to indicate that pressure area care had been carried out and changes of position had been made. When interviewed, the deputy manager was knowledgeable regarding the care of those with pressure sores. She provided evidence that staff had liaised with the tissue viability nurse regarding pressure area care. We examined the administration of medication. There is a photo of each resident in the Medication Administration Record, MAR folder. All MAR sheets were examined. They were appropriately signed. Medication was stored in a locked cabinet which is secured to the wall. Some medication were also stored in the fridge. The daily recorded temperatures of the fridge and freezer were satisfactory. Details of allergies that residents have were recorded prominently either on the MAR charts or in the front of their case records. There is a record of medication received and disposed of. We note that precautions needed in the use of oxygen had been taken. This included warning signs on doors. The deputy manager informed us that she carried out regular audits. In addition, she stated that the local pharmacist had also visited the home to carry out audits. We further note that the weight charts of residents had been filled in and were attached to the MAR charts. We discussed the care of residents during the hot summer period. The manager and her deputy were knowledgeable regarding action to take to safeguard residents from dehydration. They stated that staff had been instructed to offer drinks to residents at regular intervals during the day. Information leaflets on how to cope with the hot weather were on display along the corridor. All bedrooms inspected had a jug of water by the bedside. Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 14 The manager informed us of an example of good practice. She indicated that there are leaflets in the home publicising “Dignity in Care” and these were aimed at ensuring that staff treat all residents with respect and dignity. The home appointed a staff member in March of this year as “a Dignity in Care Champion”. We were informed that her role is to promote dignity and compassion in care in the home. This staff member would observe staff interaction with residents and ensure that staff treat all residents with respect and dignity. The manager informed us that staff behaviour and approach towards residents had improved significantly. Residents and those interviewed by us indicated that they had been well treated and no complaints were received by us. Kenwood DS0000010457.V376139.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 12, 13, 14, 15 The daily life, meal arrangements and routines of residents were on the whole, well organised. The service had a strong commitment to enabling residents to remain as independent as possible and engage in meaningful activities. Personal and family relationships were being maintained. Residents are able to choose what activities they can engage in. EVIDENCE: The home’s AQAA made the following statement: “There is a varied activity programme run by an enthusiastic activity coordinator and activities are flexible and varied to suit residents’ expectations, preferences and capabilities. Comprehensive life histories provide background Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 16 information from which to make activity suggestions and allow staff to better understand the needs and/or preferences of the residents. Individuality is encouraged throughout the day and staff are available to assist residents as required. All activity session are open to families and friends. Residents are able to express their choice with regard to leisure, social activities and cultural interests, food, meals and mealtimes, routines of daily living, personal and social relationships and religious observance. Activity organisers seek the views of the resident in order to promote a variety of daily activities. These plans are regularly reviewed and can be changed to meet individual needs. There is an open visiting policy where visitors are welcome at any time and facilities are available for them to have a drink or meal with the resident. Information of community events and activities are displayed throughout the home. ” We note that residents appear relaxed and able to move about freely in the home. Some were in their bedrooms while others were in the lounge. On both days, we note that staff made the effort to engage residents in activities and there was interaction with residents. The manager informed us that activities have been organised for residents. We noted that the notice board in the corridor contained information regarding a range of social activities and entertainment that the home provides. The manager stated that she had made effort to improve the activities programme. She stated that the activities organiser works full time. We interviewed the organiser. She informed us that there is a range of activities for residents which include arts and crafts, exercise, music, entertainment sessions and one to one sessions with residents. Residents interviewed said that they were generally happy with the social activities and entertainment that the home provides. The arrangements for the provision of meals was discussed and the kitchen was inspected. We note that the kitchen had been awarded 4 stars by the local environmental health officer. It was adequately equipped and clean. Daily recorded temperatures of the fridge and freezer had been kept. These were satisfactory. A fire blanket was in place. The menus examined appeared varied and balanced. The manager informed us that residents had been consulted regarding their likes and dislikes and their cultural observances had also been noted. We were present when lunch was served. We note that aprons were worn by staff assisting residents with their meals. Residents interviewed said that they were satisfied with the meals provided. The chef demonstrated a good understanding of the dietary needs and preferences of residents. She stated that she visits residents each day to check on their meal preferences and provides alternative meals when needed. Two residents interviewed stated that their cultural dietary preferences had been responded to Kenwood DS0000010457.V376139.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 16, 18 The arrangements for responding to complaints and for adult protection were on the whole, satisfactory. The home has an open culture that allows residents to express their views and concerns in a safe environment. This ensures that residents are well treated and protected from abuse. EVIDENCE: In the area of Complaints and Protection, the homes AQAA stated that they protect the rights of residents and work to ensure that residents are happy in the home and well cared for. They indicated that they invite relatives to communicate with them and share their views. The AQAA stated: “ We encourage expressions of concern or complaints. The policy ‘How to complain’ is framed and found in the main corridor. Complaints and concerns are dealt with asap.” Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 18 The home has an adult protection procedure. It included examples of abuse and guidance to staff on reporting allegations of abuse to Social Services and The CQC. The local authority guidelines were also available. The manager and her staff were aware of the policy and procedures for the protection of vulnerable adults. There was evidence in staff files that staff had been provided with adult protection training. When interviewed, the manager and her staff were aware of the procedure to follow when responding to allegations or incidents of abuse. We note that an allegation of abuse had been brought to the attention of a social worker during a care review carried out soon after the last inspection. This allegation had not previously been reported to Social Services or to us and the previous manager had investigated it himself. This is unsatisfactory as it is not in accordance with the accepted adult protection guidelines and procedures. This was discussed with the new manager who admitted that this was an oversight and agreed that vigilance will be exercised in future to ensure that the proper adult protection procedure is followed. The home has a complaints book. No complaints had been recorded since the last inspection. The manager explained that none had been received. When asked, residents said they knew who to complain to if they wanted to make a complaint. The manager informed us that relatives and residents are also invited to their specially allocated sessions on Wednesdays to voice any concerns or complaints they may have. These sessions are publicised in the reception area. The home has a record of compliments received. Comments made included the following : “I like to thank all staff at Kenwood for the care and attention to my mother.” “Everyone has shown such kindness and consideration to my mum.” “Just a big Thank you for all the care you have given to my mum.” “Thank you for all the kind and courteous treatment we always receive.” “We were delighted to find she rejuvenated under your care.” Kenwood DS0000010457.V376139.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 19, 23, 24, 26 The home provides a physical environment that is aimed at the individual and specific needs of people who live there. It is clean, tidy and well furnished. The manager had ensured that the physical environment is well maintained. Residents can personalise their bedrooms to make them more homely. Overall, the home provides a pleasant and comfortable environment to live in. EVIDENCE: Residents and relatives who were interviewed stated that they were satisfied with the accommodation provided for residents. The premises were inspected and found to be well furnished. The maintenance person of the company Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 20 informed us that he visits the home regularly and ensures that repairs are promptly carried out. Bedrooms inspected had been personalised by residents with their own pictures and ornaments. They appeared cosy and the chairs felt comfortable. The garden was attractive and colourful. All areas of the home were clean and tidy. No offensive odours were detected. The laundry was located on the ground floor and the staff member in the laundry was aware of the required arrangements for the laundering of soiled linen aimed at preventing cross infection. We note on the first day of inspection that there was no hot water to two bedrooms and a bathroom on the first floor. This was brought to the attention of the manager. Prompt action was taken by the manager and the water supply was reinstated by the maintenance person. This was noted on the second day of inspection. The maintenance person explained that there had been some blockage in the flow of hot water. Wheelchairs, zimmer frames, hoists and assisted baths were available for the use of residents who need them. A ramp was provided for access to the front door and garden. Kenwood DS0000010457.V376139.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 27, 28, 29, 30 The service has a good recruitment procedure that is followed in practice. The manager recognizes the importance of training and tries to deliver a programme that meets statutory requirements. Residents and their representatives are satisfied with the staffing arrangements. EVIDENCE: Six staff who were on duty were interviewed on a range of topics associated with their work. They were able to provide appropriate answers and demonstrated a good understanding of the needs of residents and how those needs are to be met. Staff stated that they had been instructed by the manager to treat all residents with respect and dignity regardless of their race, religion, culture, disability or sexual orientation. This was also a part of the induction programme which was examined by us. Residents and relatives who were interviewed indicated that staff were always respectful, caring and polite. Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 22 We noted that staff were friendly and helpful during this inspection and visitors were made welcome in the home. The duty rota was examined. Staffing levels were as follows: Am shift – 2 nurses and 5 care staff Pm shift -2 nurses and 2 care staff Night shift – One nurse and two care staff (waking night duty) The manager and deputy manager were supernumerary. Ancillary staff working at the home comprise of two kitchen staff and two cleaners. The home also has a full-time activities organiser. There were 27 residents in the home during this inspection. Staff stated that the staffing levels were generally adequate and they were able to perform their duties. The manager provided evidence that the staffing levels had been reviewed and she was of the opinion that staff were able to meet the needs of residents. She further reassured us that if additional staff are needed, they would be provided. The training records examined, indicated that staff had been provided with the required training. The recruitment records examined indicated that the required recruitment procedures (including obtaining of satisfactory CRB and POVA disclosures, evidence of identity and two references) had been followed. We note that two new staff had started work with only POVA disclosures were in the process of receiving their CRB disclosures. The manager stated that they were always accompanied when attending to residents. However, she did not provide us with a written procedure. This is needed to provide guidance on the use of staff who only have a POVA disclosure. The procedure must reflect guidance provided by us. The manager agreed to look into this matter. (We have been informed by the manager that the two staff concerned have now received their CRB disclosures). Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 31. 33. 35. 38 People living in the home can be assured that the home is generally well run and the manager and her deputy have the experience and ability to deliver a good quality of care and meet it’s stated aims and objectives. Records are well maintained. There is a system for maintaining health and safety. Residents and their representatives are consulted regarding the care provided and the management of the home. EVIDENCE: Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 24 In the area of Management and Administration, the AQAA stated : “The manager ensures the approach of the home remains open, positive and with an inclusive atmosphere. A commitment is made to equal opportunities. Methods of running the home are transparent. Management planning and practice encourages innovation, creativity and development. The manager develops good relationships with residents and their representatives and ensures that their opinions are considered when reviewing the services offered. The manager promotes a working environment where the skills and knowledge of the staff are valued and considered at every opportunity. The manager promotes good communication with other authorities and manages the home in an open and transparent manner. Comprehensive quality assurance processes are in place.” During this inspection we note that the new manager was aware of the importance to ensure that the home is well managed and residents are well cared. She informed us that the service is closely monitored by her and her deputy. She stated that she has the RMA (Registered Manager’s Award). In addition, she stated that she had worked as the home’s administrator for several years and was familiar with the running of the home. Although she does not have nursing qualifications, she informed us that she is assisted by the deputy manager who is a qualified nurse and nursing decisions are referred to her. In the absence of the deputy manager, she informed us that an allocated nurse would oversee and make decisions regarding nursing care issues. The operations managers who were present reassured us that they visit the home regularly to provide support and monitor the quality of care provided. There was evidence that staff and residents’ meetings had been held and issues regarding the running of the home had been discussed with those present. The minutes of these meetings were available for inspection. Residents interviewed were able to confirm that they had been consulted. Consumer surveys had also been carried out and there was a published report. The home has a current certificate of insurance. Three residents’ financial records were examined. These were well maintained and contained receipts for money spent on behalf of residents. The home has a comprehensive range of policies and procedures. We discussed The Mental Capacity Act 2007 and it’s implications for residents and staff. The manager stated that she had attended relevant training in this area and the home has the relevant policy and procedure. Effort had been made to ensure the health & safety of those in the home. The manager was noted to be knowledgeable regarding fire safety and the necessary fire safety arrangements were in place. The weekly fire alarm tests Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 25 had been carried out and documented evidence was provided. Fire drills and fire training had been organised and documented over the past twelve months. A fire drill had been carried out after dark. This ensures that staff are fully aware of action to take in the event of a fire. The fire risk assessment had been updated. Fire exits were kept clear. Staff interviewed were aware of the procedure to follow in the event of a fire. Following a requirement made in the last inspection report, there was documented evidence that the fire door guards in place had been tested weekly and were in working condition. We note on the first day of inspection that some excess furniture was left near the fire exit (under the fire escape stairs) on the side of the home facing the conservatory. This was brought to the attention of the manager who arranged for them to be removed. Excess furniture must not be left near the fire exits. This is to ensure that the safety of residents and staff in the event of a fire. The manager indicated that she would ensure that this is not repeated. The accident and incident book was examined. Significant incidents had been recorded. We however, noted that there had been two instances when money had been reported to have either gone missing or been stolen. Although the Police were informed, Regulation 37 notifications were not submitted to us and Social Services were not informed. This was discussed with the manager and the regional manager who agreed that appropriate action would be taken in the future and the notifications would be made. Safety inspections had been carried out on the portable appliances and gas installations. The five year electrical installations safety inspection and the gas inspection had been carried out and the certificates were seen. Window restrictors in the home were in place and engaged. We note that bedrails had been used for residents and the assessment forms had been signed by care staff and relatives concerned. This was discussed with the manager and area manager. To ensure that appropriate care and safeguards are in place, professionals (such as the social worker and GP) involved with the residents concerned should also be consulted. Evidence of this consultation should be provided in the case records. The area manager agreed to review the procedure. Kenwood DS0000010457.V376139.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 X 3 X x n/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 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 2 3 X X X 3 3 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 3 X 3 X 3 X X 2 Kenwood DS0000010457.V376139.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 OP18 Standard Regulation 13(6) 37 Requirement All allegations of abuse must be reported promptly to Social Services and The Care Quality Commission. This is to ensure the protection of residents. 2 OP29 19 The home must have a written procedure for the use of staff who only have a pova disclosure. This is to provide the necessary guidance on working arrangements and to ensure the protection of residents. 3 OP38 37 Significant incidents, including theft of money must be notified to The Care Quality Commission. This is to ensure the registration authority is kept informed and for the protection of residents. 4 OP38 13(4) DS0000010457.V376139.R01.S.doc Timescale for action 17/08/09 14/09/09 24/08/09 24/08/09 Version 5.2 Page 28 Kenwood Excess furniture must not be left near the fire exits. This is to ensure that the safety of residents and staff in the event of a fire. 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 OP38 Good Practice Recommendations The procedure for using bed rails should be reviewed to ensure that the views of professionals involved with residents concerned are noted. This is to ensure that relevant information is obtained and appropriate care and safeguards are in place to protect residents. Kenwood DS0000010457.V376139.R01.S.doc Version 5.2 Page 29 Care Quality Commission National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Kenwood DS0000010457.V376139.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. 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