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The Kensington Gardens

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The Kensington Gardens (25 Brunswick Avenue, Toronto) is operated by The Kensington Health Centre. The facility has a capacity of approximately 350 beds.

In this article, our Good Caring Canada team has reviewed The Kensington Gardens from three essential angles: inspection reports, performance indicators, and resident profiles. You are encouraged to thoroughly review all three angles so you can be more informed about the quality and safety of The Kensington Gardens.

Table of Contents:

Inspection Reports for The Kensington Gardens

The Kensington Gardens is regulated by the Ontario Ministry of Health and Long-Term Care. The Ministry conducts inspections of all long-term care facilities to ensure that operations are in compliance with provincial regulations, and that residents receive proper care.

Our Good Caring Canada team has summarized inspection reports for The Kensington Gardens. Original copies of the inspection reports can be read in the Government of Ontario website.

🔍  March 2024: Inspection

There were no findings of non-compliance.

🔍  February 2024: Inspection

The inspection for The Kensington Gardens, addressed three main intakes. The intakes involved complaints related to improper care of a resident, alleged neglect of a resident, and an unknown injury.

  • Plan of Care: The licensee did not document the use of a medical device in a resident’s plan of care. This oversight, including the absence of documentation and intervention plans, posed a risk of inconsistent and improper care for the resident.
  • Infection Prevention and Control: The licensee failed to ensure proper use of Personal Protective Equipment (PPE) as required by infection control protocols. Staff did not follow routine practices and additional precautions, posing a risk to resident health due to improper infection control.
  • Administration of Drugs: The licensee did not administer medication according to the prescriber’s directions. A resident missed scheduled medication doses due to the unavailability of the medication and failure to follow the medication management process, posing a risk to the resident’s health.

🔍  December 2023: Inspection

The inspection for The Kensington Gardens, addressed two main intakes. The intakes involved alleged improper/incompetent care of a resident by staff.

  • Plan of Care: The licensee did not ensure that the care set out in a resident’s plan of care was provided as specified. During the inspection, it was observed that a resident was using a different transfer device than what was indicated in their plan of care. This was confirmed by the Clinical Manager, posing a risk of improper care for the resident.
  • Reporting to Director: The licensee failed to ensure immediate reporting to the Director of an incident involving improper care. A staff member used an incorrect transfer method, and the incident was not reported until the next day. This delay in reporting could have resulted in delayed corrective actions.
  • Transferring and Positioning Compliance: The licensee did not ensure staff used safe transferring and positioning techniques for two residents. One incident involved a staff member transferring a resident in an unsafe manner, contrary to the resident’s care plan. Another incident involved a staff member transferring a resident without the required assistance. An auditing process was ordered to ensure compliance, including frequent audits and corrective actions.

🔍  November 2023: Inspection

The inspection for Hogarth Riverview Manor, addressed one main intake. The intake involved a resident who went missing from the home for more than three hours.

  • Plan of Care: The licensee did not ensure that a resident was reassessed and their plan of care reviewed and revised when the care set out in the plan had not been effective. Despite being known to remain off their home area, the resident’s plan required staff to perform specified monitoring, which staff found unfeasible. Both a Clinical Resource Consultant (CRC) and Interim Clinical Manager (ICM) acknowledged that the current monitoring process was unrealistic and that the resident would not comply with the home’s monitoring policies. The failure to revise the plans of care presented a moderate risk of harm to residents without their assessed safety checks being provided.

🔍  September 2023: Inspection

The inspection for Hogarth Riverview Manor addressed several intakes, including issues related to fall prevention, provision of care, medication management, incidents of resident-to-resident physical abuse, staff-to-resident neglect, an unexpected death, a resident fall with injury, and an allegation of staff-to-resident physical abuse.

  • Plan of Care: The licensee did not ensure that the staff providing direct care to a resident were aware of the contents of the resident’s plan of care and had convenient and immediate access to it. A resident’s plan of care binder lacked up-to-date information, which was corrected during the inspection by updating the binder with the current care plan and recommendations.
  • Nutritional Care and Dietary Services: The licensee did not fully implement the nutritional care and dietary services program. A resident experienced significant weight loss, and staff did not refer the resident to a dietitian as required by policy, delaying necessary interventions.
  • Collaborative Plan of Care: The licensee did not ensure collaboration among staff in the development and implementation of a resident’s plan of care. Conflicting information about the type of assistance required for an activity of daily living (ADL) led to a fall incident, though no injury occurred.
  • Duty to Protect: An incident occurred where a Registered Practical Nurse (RPN) treated a resident inappropriately, resulting in injuries. The incident was investigated and confirmed by the home, posing a moderate risk to the resident. A resident was not provided with repositioning, hydration, or continence care over an extended period, leading to impaired skin integrity. The home’s investigation determined that staff did not provide the required care, resulting in moderate harm to the resident.

🔍  July 2023: Inspection

The inspection of Hogarth Riverview Manor, addressed multiple intakes involving a medication error, a missing controlled substance, resident care concerns, and an allegation of abuse.

  • Administration of Drugs: Non-compliance with medication administration protocols resulted in a resident not receiving prescribed medication due to documentation errors, posing risks to health and safety.
  • Medication Management System: Failure to document narcotic administration correctly according to policy led to discrepancies in medication records, indicating lapses in procedural adherence.
  • Infection Prevention and Control Program: Shortcomings in implementing hand hygiene and PPE protocols were observed, despite existing guidelines, potentially compromising infection control measures.
  • Plan of Care Documentation: Inadequate documentation of care provided as per resident care plans during specific shifts highlighted deficiencies in monitoring and maintaining consistent care standards.
  • Duty to Protect: Concerns of resident abuse and improper care practices were substantiated, underscoring failures in safeguarding residents and adhering to care plan directives.

🔍  January 2023: Inspection

The inspection of Hogarth Riverview Manor, addressed various intakes including integration of assessments, duty to protect, altercations between residents, safe drug storage, resident care concerns, infection prevention and control issues, resident-to-resident physical abuse, staff-to-resident physical abuse, and incidents related to resident falls resulting in injury.

  • Policy to Promote Zero Tolerance: Non-compliance with the abuse policy was identified when staff failed to report an incident involving a resident being abused by PSWs and an RPN. Despite witnessing the abuse, staff did not follow the home’s policy, impacting resident safety with a moderate risk and no lasting physical or emotional harm reported.
  • Reporting Certain Matters to the Director: The failure to immediately report allegations of resident abuse to the Director was noted when an incident involving resident injury due to another resident was reported late, without notification through the after-hours pager system. This lapse posed a low impact and risk to the resident.
  • Restraining by Physical Devices: Instances of non-compliance with the requirement for physician or nurse approval for the use of physical restraints were observed. One resident had a safety device without documented authorization, while another had a device improperly applied, highlighting deficiencies in care plan adherence and documentation.

🔍  August 2022: Inspection

The inspection for Hogarth Riverview Manor, addressed multiple intakes. The intakes involved multiple complaints regarding resident care, incidents of resident-to-resident physical aggression, and allegations of staff-to-resident abuse.

  • Failure to Report Allegations of Abuse: During the inspection, it was noted that several allegations of abuse were not promptly reported to the Director. For example, incidents involving a significant injury to a resident allegedly caused by a Personal Support Worker (PSW) and allegations of abuse by PSWs towards multiple residents were not reported in a timely manner.
  • Non-Compliance with Continence Care Standards: The inspection identified instances where the facility failed to consistently implement individualized continence care plans for residents, resulting in incidents of incontinence. This deficiency posed a moderate risk to the affected residents’ well-being.
  • Deficiencies in Nutritional Monitoring: There was a failure to promptly refer a resident with decreased dietary intake to a Registered Dietitian (RD), contravening regulations outlined in the FLTCA. This oversight posed a high risk to the resident’s health, requiring immediate corrective actions and staff re-education.
  • Incidents of Resident Abuse: Several instances of alleged physical and emotional abuse by PSWs towards residents were substantiated during the inspection. These incidents highlighted systemic failures in protecting residents from harm, resulting in Compliance Orders and an Administrative Monetary Penalty (AMP) issued against the licensee.
  • Medication Management Violations: Inspection findings revealed that medication carts were often found unlocked and unattended, violating safety protocols for drug storage. This oversight posed a potential risk to resident safety and necessitated immediate corrective measures.
  • Intervention and Response to Resident Altercations: The inspection noted deficiencies in implementing effective interventions to prevent altercations between residents with documented histories of aggressive behaviors. This failure compromised resident safety and prompted a comprehensive review and implementation of corrective measures.

🔍  March 2022: Critical Incident Inspection

The inspection for Hogarth Riverview Manor, addressed multiple intakes. The intake involved related to improper transfer.

  • Improper Transfer: A Personal Support Worker (PSW) proceeded with transferring a resident in their room without waiting for additional staff assistance, despite being instructed to do so by a Registered Practical Nurse (RPN). This action was contrary to the facility’s policy which mandates two staff members for mechanical lifts and adherence to a safety checklist. The improper transfer endangered the resident and staff, highlighting lapses in adherence to established safety protocols.

Performance Indicators for The Kensington Gardens

Our research team at Good Caring Canada has compiled data on seven key performance indicators for long-term care facilities in Ontario.

We invite you to review each of the below indicators — to compare The Kensington Gardens with other long-term care facilities in Ontario.

  • 🤕  Fall risk is measured by the percentage of residents who fell in the 30 days leading up to the date of their quarterly clinical assessment
  • 🦽  Worsened physical functioning is measured by the percentage of residents who worsened or remained dependent in transferring and locomotion (mid-loss ADLs), less residents who improved or remained independent
  • 🩹  Worsened pressure ulcers is measured by the percentage of residents whose stage 2 to 4 pressure ulcer worsened since the previous assessment
  • 😣  Pain is measured by the percentage of residents who report to have moderate daily pain or horrible/excruciating pain at any frequency
  • ☹️  Worsened depressive mood is measured by the percentage of residents whose mood from symptoms of depression worsened

Resident Profile of The Kensington Gardens

Understanding the resident profile of a long-term care facility can help you assess the facility’s appropriateness and compatibility for a patient. Our research team at Good Caring Canada compiled data on three main elements to understand resident profiles. We invite you to review each of the three below elements.

  • 👵🏻  Gender profile can be helpful for assessing the gender compatibility of a long-term care facility.
  • 👴🏻  Age profile can be helpful for assessing whether a long-term care facility has experience in caring for residents of specific age groups. More residents of advanced age may imply potential challenges to adequate and equitable care for all residents in the facility.
  • 💭  The percentage of residents with dementia can be helpful for assessing whether a long-term care facility is aware and ready for dementia care. A higher percentage may imply more relevant care services. A higher percentage may also imply potential challenges to adequate and equitable care for all residents in the facility.

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