Kenward House

In February 2019 we undertook a comprehensive inspection of Kenward House. We did not publish a report following the inspection, as we were unable to produce a report within our timeframes. However, we did issue two warning notices to the provider because we had serious concerns about the safety of patients due to a lack of robust assessment and planning relating to the safety, health and well-being of clients; lack of adherence to the providers own admission criteria; environmental risks; a lack of skilled and experienced staff and a lack of robust governance processes to oversee the quality and safety of the service.

We undertook a comprehensive inspection on 1 July 2019. During the inspection we looked at whether the provider had made the improvements required to comply with the regulations.

During this inspection we found that the provider had acted on the warning notice and made the improvements required.

We rated the rated Kenward House good because:

• Risk assessments were comprehensive and tailored to the needs of individual clients. Risk assessments included consideration of physical health, mental health, social, substance misuse, financial and criminal justice history. The majority of staff had completed risk assessment training.
• The service had appropriate equipment available to support the monitoring of physical health. This included weighing scales and blood pressure monitors. Staff had completed training in the management of diabetes and epilepsy.
• Staff completed monthly environmental health and safety audits., Documentation had been improved and actions were now easily identifiable. Work was taking place to improve the décor in the bedrooms and ensure essential repairs and maintenance was completed in a timely manner. The door to the main kitchen was kept locked.
• The provider had introduced a ligature point risk assessment guidance and confirmed that staff had now completed environmental ligature point risk assessments.
• The provider had made changes to improve the admissions process to make sure the service was able to meet the needs of clients.
• There was a comprehensive system to manage planned and unplanned exit from treatment. It included information about what staff should do if a client left the service before they had completed their treatment.
• An inspection by the fire service had taken place and the provider now complied with. The Regulatory Reform (Fire Safety) Order 2005.
• Staff issued clients with wrist alarms so that clients could contact them in an emergency.
• Staff reported incidents appropriately. Managers investigated incidents and shared lessons learned with staff and the wider service. Staff completed a root cause analysis for serious incidents. We saw an example of learning from medicine incidents shared with staff.
• Managers completed regular audits of care records to make sure that staff were adhering to the provider’s health and wellbeing strategy and that client records were accurate and up to date. In addition, there was an annual audit programme and effective oversight mechanisms to ensure improvements were made.
• The provider used systems and processes to safely prescribe, administer, record and store medicines. Medicines errors were minimal and were reported, investigated and lessons learned.
• Staff had a good understanding of safeguarding procedures and knew what to report and how to report it. The provider was in the process of reviewing its policy at the time of the inspection.
• There was a comprehensive group activity programme between 9am and 4.30pm Monday to Friday. The provider had developed links with the careers service who facilitated basic literacy and numeracy courses at the service. Social enterprise projects were available for clients to increase their recovery and support their return to independent living.
• Clients said that staff treated them with compassion, dignity and respect. They said that staff were supportive in their recovery journey and the treatment had changed their life.
• The provider produced a regular newsletter with information about the service and forthcoming events. The service planned to introduce an information pack for families and carers of clients.
• Managers were visible, approachable and had the knowledge and experience to perform their roles. There was a clear framework of what should be discussed at team, manager and board level to ensure that essential information was shared. The chief executive attended weekly meetings to provide service updates for staff. There was commitment towards continual improvement and innovation. Staff were able to contribute to the strategy and service development.

However:

• Information provided by the service showed that only 66% of staff had completed mandatory training. Less than 50% of staff had completed the training for self-harm and suicide, mental health first aid, and naloxone. Staff had not completed training in the Mental Capacity Act. After the inspection, the provider confirmed that it had made arrangements for staff to complete this training.
• Records of admission panel meetings lacked detail and did not provide a clear rationale of the decision-making process about whether clients should be admitted or not.