Please wait

Inspection on 26/01/10 for Kirkstall Court Care Home

Also see our care home review for Kirkstall Court Care Home for more information

This is the latest available inspection report for this service, carried out on 26th January 2010.

CQC found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is well placed within the local community and there is a range of local amenities within easy reach. This is of particular benefit to those admitted to the Champion Crescent unit for rehabilitation. The staff are pleasant and welcoming and relate well to people who live at the home. Visitors are made very welcome at the home. There is good support on the older person`s unit from other healthcare professionals. The GP visits every week and the community matron also provides regular weekly support to the older person`s unit. People said: "The home looks after me and they try to help me the best they possibly can" "Staff communicate with us well and are always friendly and approachable" "I am getting looked after very well"

What has improved since the last inspection?

The information in the care files on the older person`s unit is easier to access and this means that staff have access to the information they need to know how to look after people.

What the care home could do better:

Although the care records on the older person`s unit have improved work needs to continue to make sure that records have enough detail about people`s strengths and their preferences. Champion Crescent - The provider needs to review the way this unit is managed to make sure that people are having their healthcare needs looked after by building up contacts with other healthcare professionals who might be able to support staff in caring for this client group. The provider also needs to make sure that there is enough support for the care staff who work in this specialised unit. Staff need to have further safeguarding training to help them to fully understand their responsibilties in keeping people safe, particularly when people do not have full capacity. This is to make sure that people are kept safe. Further detail can be found in the body of the report. Recommendations can be found at the end of the report.

Key inspection report Care homes for older people Name: Address: Kirkstall Court Care Home 119-129 Vesper Road Leeds Yorkshire LS5 3LJ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Catherine Paling     Date: 2 6 0 1 2 0 1 0 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 31 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. 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 Care Homes for Older People Page 3 of 31 Information about the care home Name of care home: Address: Kirkstall Court Care Home 119-129 Vesper Road Leeds Yorkshire LS5 3LJ 01132591111 01132257444 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Dukeries Healthcare Limited care home 38 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of users who can be accommodated is: 38 The registered person may provide the following category 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 Physical disability - Code PD Dementia Code DE Date of last inspection Brief description of the care home Kirkstall Court is a purpose built home, dating from 1991. The current providers have been registered since June 2000. The home provides personal care with nursing for up to 30 older people and very much serves its local community. In addition there are 8 places for the rehabilitation for under 65s with alcohol related dementia. 0 9 0 2 2 0 0 9 38 0 1 Over 65 0 30 0 Care Homes for Older People Page 4 of 31 Brief description of the care home Accommodation for people is provided over three floors with single rooms, all of which have en-suite facilities. There is a passenger lift providing access to the upper floors. The home is on the main bus route into Leeds city centre, four miles away. It is also close to local shops and a post office. The local pub is a short car journey away, close to Kirkstall Abbey and museum. There are seating areas outside the home, which are accessible to people by means of a ramp. Information about the home and services provided are available in the form of a statement of purpose and service user guide for the elderly unit and for the dementia care unit, which is known as Champion Crescent. Copies of inspection reports are also available at the home. The current scale of charges range from a minimum of £497 on the elderly care unit up to £824 on Champion Crescent. This information was provided at the January 2010 visit. Fees are reviewed in April each year and the home should be contacted directly for up to date information about charges. Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced visit by two inspectors who were at the home from 09:40 until 18:00 on 26th January 2010. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. A number of documents were looked at during the visit and most of the areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people who live at the home, as well as with the staff and the Care Homes for Older People Page 6 of 31 manager. An Annual Quality Assurance Assessment (AQAA) had been completed by the home before the visit to provide additional information. This is a self-assessment of the service provided. Survey forms were sent out to the home before the inspection providing the opportunity for people at the home, visitors and healthcare professionals who visit, to comment, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. A number of surveys were returned by the time of this visit. Comments received appear in the body of the report. The last visit to this service was 9th February 2009. Care Homes for Older People Page 7 of 31 What the care home does well: What has improved since the last inspection? What they could do better: 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. Care Homes for Older People Page 8 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with enough information about the service to help them make an informed choice about moving into the home. People have their needs assessed. Evidence: The manager wrote in the AQAA: All the information that residents and potential residents need is contained within the Service User Guide. We have a Statement of Purpose which is reviewed regularly. The latest inspection report is available for perusal. The complaints procedure is clearly displayed in the reception area. Potential residents and their families/friends are encouraged to view the Home and also to spend a/part of a day/night with us. This will not always be possible for the prospective resident to do. For example if a prospective resident is hospitalised prior to admission. Having said that, despite being hospitalised, the most recent person to be admitted to Kirkstall Court Care Home spent part of a day with us and had a meal at the home with their relative. They were able to look at the room of their choice again and ensure that they had picked the room that most suited them. This process Care Homes for Older People Page 10 of 31 Evidence: helped the resident to feel empowered about making an informed choice both about whether they would come into care and also about whether they wanted to join us at Kirkstall Court Care Home. Champion Unit residents can be accepted from all over the UK. Nearly all prospective Champion Unit residents will visit the unit prior to admission to meet the staff, their potential peers, and to get a feel for the services we provide and whether they appear pertinent to themselves. All admissions are planned in advance whenever possible and a full assessment is carried out by the Home Manager/Deputy Manager/ Unit Manager prior to admission. The assessor consults with other professionals as well as the potential resident and relative. We always insist on seeing a copy of the prospective residents care plan and whenever possible a more comprehensive assessment. The latter is especially important within our rehabilitation service for residents with alcohol related brain injury. The people who contribute towards the assessment are documented. Relatives/friends are encouraged to accompany the person on admission to help them to settle in. They are also encouraged to personalise the residents room in order to make it feel more homely. Contracts, which include fees charged, are issued to all residents and a copy is kept in the Service User Guide. We provide respite care to give residents and their relatives a break. We have an open visiting policy. There is a range of information available for people about the service to help them decide about moving into the home. The service users guide is provided to everyone and we saw that it is updated regularly, most recently in November 2009. Following some safeguarding issues early in 2009 the local authority contract was suspended and so there have not been any recent admissions to the home. The service have worked with the local authority to make improvements and the contract was reinstated in January 2010. There is an assessment tool available and everyone has their needs assessed before moving into the home. Care Homes for Older People Page 11 of 31 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall, care plans contain enough information so that the staff know how to look after people properly. Some information about people is not kept in individual care files. This means that there is a risk that some needs may not be fully understood by staff. People are protected by safe medication procedures. Evidence: The manager wrote in the AQAA: Each resident has plans of care that they and/or their relatives/friends have been involved in making. The care plans are easy to follow and are accessible to residents, care staff, and relatives. The care plans refer to the residents strengths as well as their weaknesses. The acivities of daily living are covered. The assessment covers to the six strands of diversity ie gender, age,sexual orientation, race, religion and disability. We record the preferred communication method of individuals. Residents who can manage their own medication are risk assessed with regard to the safety of this. Residents who cannot manage their own medication are supported to do so by Registered Nurses on the elderly side and Senior support staff on the Champion unit.Staff respect the individuality of each resident and Care Homes for Older People Page 12 of 31 Evidence: their right to make choices and to take risks were possible. Peoples right to privacy and dignity is respected and the staff support residents in a way that promotes privacy, dignity and maintains as much of their independence as is possible. When residents have specialised and/or complex needs the advice of an expert ie Tissue Viability Nurse, Infection Control Nurse is sought and a plan of care is formulated on the advice given by such an expert. Whenever possible we ask the expert to also help us to review the efficacy of the plan of care. When a resident reaches the end of their life their wishes and the wishes of the people closest to them are respected. The resident is assured that staff will help them to be comfortable and that their death will be dealt with with respect and dignity taking into account their spiritual and cultural wishes. We have a Community Matron who visits weekly. We have a GP who visits every week and with whom most of the residents are registered. When we have encountered a problem when the individuals right to choice has been in conflict with the need to prevent the person from harming themselves we have consulted extensively with the resident, family, and other professionals to establish capacity and best interest decisions. We hold regular resident/relative/friend meetings in order to allow our residents and relatives to influence and contribute to the day to day running of the Home. These meetings are minuted and always begin with discussion as to what has been done about the matters which arose in the previous meeting/s. We provide a nutritious and varied diet. The residents also have fresh fruit available to help themselves to. They also have nutritious snacks provided in between meals. We carry out annual customer satisfaction surveys to ascertain what we are doing well and what we still need to improve on. Regular church services are held to cater for the spiritual needs of the residents. Improvements noted by the manager: Our care plans on the elderly side are no longer written in the first person and a recent review of all care plans showed significant improvements had been found by the auditors. We have changed our medication supplier. We change our menu schedules to accomodate the likes and dislikes of our residents. We present the tables at mealtime in an attractive way and ensure that condiments and seasoning are available. We have sourced bread that is more varied and therefore appertising. People said in surveys: The home looks after and they try to help me the best they possibly can. Unfortunately, they can not give me the help that I need. Staff communicate with us well and are always friendly and approachable. The home has helped me get back on my feet, I am very grateful for that and hope to keep in touch when I leave to let them know what I achieve when I leave. I am getting looked after very well. I would like the staff to allow me to wake up on a morning of my Care Homes for Older People Page 13 of 31 Evidence: own according. However I do understand it is for my medication. We looked at a small number of individual care records for people on the older persons unit and on Champion Cresecent. Older persons unit - We saw that the care records have been reviewed since our last visit to make sure that staff have access to the information they need so that they can look after people properly. We saw that people had their needs assessed before admission to the home. The document used is detailed but not fully utilised by staff. For example we saw that one assessment had not been signed by the person completing it. There was not enough information on this document for people to be clear about the care and support this person needed. For example, when assessing washing and dressing the information recorded said needs supervsion and independant. This is confusing and does not provide clear information about individual strengths, weaknesses or preferences. There is an activities of daily living assessment completed within fourteen days of admission. This does provide a good overview of preferences and strengths. We saw that this document helps staff to identify where a plan of care is needed. We saw that the information in care plans was brief and that it needs expanding in places to make sure that staff had all the detail they need to look after people in the way they want to be. For example, the care plan to address Hygiene said assist with washing and dressing without saying what this person could do for themselves and exactly what support staff needed to provide; it also said ensure teeth cleaned but didnt say when or how - it was not clear whether this persons teeth were false or not. Care plans are reveiwed on a monthly basis and some of the evaluation we saw did seem to reflect what a person could and could not do and any changes. We saw a lot of repetition in other reviews, which did not demonstrate the effectiveness of the care plan. For example, one person who has mental health issues had no outbursts or no aggressiveness recorded month after month for the care plan developed to help staff to manage the effects of dementia. The care plan was that All staff to have training enabling them to understand why X may react in certain ways. This person has been at the home for almost 10 years and staff know this person well; the way the plan is written and the review does not reflect this knowledge. Daily records are kept. The way these are currently recorded does not provide clear information about the health and welfare of a person. Care plans are numbered and in daily records the number of the plan is noted with a brief statement of care provided. Care Homes for Older People Page 14 of 31 Evidence: People on the older persons unit have their healthcare needs met and the staff at the home are well supported by other healthcare professionals. The GP visits the home every Thursday; the community matron every Tuesday afternoon and the tissue viability nurse (TVN) also visits on a regular basis. On the day of our visit we met with both the community matron and the TVN. They both felt that the service had improved with the new manager and spoke of her committment to improve the service. The TVN said that staff were keen to learn and put into practice any recommendations she makes. We also found that this was the case, for example, on one file we found a letter from the TVN about the treatment of one person. Information in the care plans had been updated to reflect the changes requested. We saw safe medication practices and staff involved in medication administration told us that they had received medication update. All aspects of medication administration are monitored internally by means of regular internal audit. Champion Crescent - The records we looked at were detailed and showed the involvement of the person in their care and rehabilitation plan. There was information about targets for the person to work towards and we saw reviews of care. Care plans include clear instructions about care so that staff know how to support the person. However, we found that in addition to the individual records staff were making detailed recordings in a communication book. Personal details of people should not be kept together in this way and does not comply with Data Protection requirements. We found conflicting information about peoples preferences recorded in individual care plans and the communication book. This means that there is a risk that individual needs may not be fully understood by staff. For example one persons care plan said they choose to have staff support to go shopping but the communication book said the person must have a staff escort at all times when they go out. One person raised concerns at the inspection that they felt as though they were serving a prison sentence.. We spoke to staff who said they had noticed a change in the persons behaviour and were monitoring them more closely, which included recording everything which is not part of their usual routine and always accompanying them when they are out. On occasions, staff had searched their room but this did not appear to have been done with the permission of the person. We could not see any evidence to show that these changes had been made with the agreement of the person or their representative or any healthcare professional. Another person who uses the service had previously raised concerns that staff boss them about. Risk assessments had been completed and were up to date. The manager of the home and the director did not realise that apart from a weekly visit from the GP no other Care Homes for Older People Page 15 of 31 Evidence: healthcare professionals were involved with people who live at Champion House. Care Homes for Older People Page 16 of 31 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported in maintaining contact with family and friends and to make choices. People are provided with a good and varied diet that takes into account individual choices. Evidence: The manager wrote in the AQAA: When planning the activities which a person participates in we take into consideration their personal choices, race, culture, religion, age, disability, gender and sexual orientation. Some of our residents manage to continue activities they enjoyed before entering the home. For example one gentleman regularly goes out to the local betting shop and has recently attended a school reunion which he obviously enjoyed. We encourage our residents to stay in touch with their families and help to make the families feel they are welcomed at Kirkstall Court and Champion Unit. Many residents receive personal phone calls from their family and friends and these are facilitated and the residents are afforded privacy during these calls. Tables are mealtimes are set to make them look attractive and to promote mealtimes as a social event instead of just being a nutritional necessity. Fresh fruit is available on the units and residents are encouraged to help themselves and are assisted if necessary. We have entertainers who come every week. We have Pets as Therapy attending the Home. Recently some of our residents enjoyed Care Homes for Older People Page 17 of 31 Evidence: attending a local theatre which had put on a production by local children. We had a residents Christmas Party on 14.12.09 which the residents and relatives enjoyed. Some of our residents have enjoyed the facilities including the cafe at nearby Kirkstall Abbey. We have Bridgewater Trust who are a special service for people with Brain Injury who visit Champion Unit weekly and work with the residents. We have residents on Champion Unit who do voluntary work within the Community. Champion residents do their own laundry, housekeeping and are supported to budget, shop and plan and cook nutritious meals for themselves. Plans for the next 12months: Develop a newsletter. Improve links with local classes and events in the community. Sadly those which we have already tried will not accept our residents as they do not consider them to be in their own home. This is a hurdle which we will continue to try to overcome. To try to include residents, who wished to be included, in more day to day activities such as housework, gardening, watching films that they have chosen, karaoke, indoor games etc. To ensure that the new activities coordinator develops programmes for those residents who need more support to participate. To ensure that new activities coordinator helps turn hairdressing sessions into pamper days with make up, nail care, hand moisturising massage etc. and thereby to turn a task into an enjoyable function. A new activities co-ordinator started work 20th December 2009. People said in surveys: The home looks after my day to day needs and keeps me in a good routine and helps me with any problems I have. I eat very well, the staff can be very helpful and are always up beat when I am down sometimes they cheer me up. They do well but I am lonely. Champion Crescent - People who live on this unit are encouraged to spend their time in a productive way, as part of their rehabilitation programme. They are given some household tasks on a rotational basis to help them re-learn life skills. Some people attend external activities. At a recent residents meeting everyone had agreed to look for more outside activities, and people who use the service were asked to think of things they would like to do. Older persons unit - The majority of people said in our surveys that staff acted on what they said and were available when they needed help. We saw that people spent their time in the way they wanted with some people having a late breakfast and others going out with friends. Visitors are welcomed at the home at anytime. There is a new activities coordinator for the older persons unit, who has only been in post for a short time. There is a programme in place, which includes entertainers coming into the home as well as in-house activities. At the time of our visit we spoke Care Homes for Older People Page 18 of 31 Evidence: with the activities coordinator while she gave one person a manicure and also a foot massage. There is a notice in the entrance area from the activities coordinator saying that it is her intention to spend time with people finding out about hobbies to help her plan activities. Relevant training is also planned. The lunchtime meal was relaxed and unhurried with staff supporting people on a one to one basis. There was a choice of food and it looked and smelt appetising. People said the food was good. The new cook has only been in post a week. We were told that all soups are home made; we saw that home baking was provided with morning and afternoon drinks; food diaries are completed for people considered to be at nutritional risk and smoothies are also provided to people to help them maintain or put on weight. One person we spoke with told us that most staff knew her very well and looked after her in the way she wanted. She felt that some staff were good and negotiated care, while others just do care to her. She said that she did spend her time in the way she wanted. Care Homes for Older People Page 19 of 31 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident in raising concerns on a day to day basis and have access to a formal complaints procedure. Overall people are protected by staff knowledge and understanding of safeguarding, although some practices put people at potential risk. Evidence: The manager wrote in the AQAA: We welcome complaints and suggestions about the home, however trivial, we will ensure issues are followed up to a satisfactory conclusion for all parties concerned whenever possible. Staff at the home take residents opinions seriously and strive to respond to their issues. Complaints books are are located in all units and the Home Manager ensures these are checked every month. The complaints procedure is at reception. Each complaint is fully investigated and the complainant is supplied with a full report following conclusion of the investigation. The home records the nature and and incidence of complaints as part of the audit process, so that we can pay attention to any themes within complaints such as care issues for example. Policies and procedures regarding safeguarding adults are available to all staff, and we have a whistleblowing policy which can be used at any time. The policy states that people can complain anonymously should they so wish. We ensure that staff are trained with regards to safeguarding adults. The home utilises other methods before considering bedrails. If these are used then we have a plan of care which involves the resident and their families wherever possible. We will always refer to the relevant authorities if we suspect a safeguarding issue has arisen. We have an open and transparent system with regard to this which means that we Care Homes for Older People Page 20 of 31 Evidence: address issues quickly and can be more proactive in our approach. CRB, POVA checks and references are central to the Homes employment policies. Information from our surveys told us that the majority of people know who they can talk to if they have concerns and also know how to make a formal complaint. There have been a number of complaints made to the service since our last visit. Information in the complaints log showed us that concerns are taken seriously and acted upon. Concerns raised included issues around staff practice and mealtimes. The local authority have been involved with the home in investigating some safeguarding incidents at the home. Placements were suspended while investigations were completed with the full cooperation of the service. The local authority wrote to the home in January 2010 reinstating placements. Staff have safeguarding training as well as training around mental capacity and the deprivation of liberties. This means that staff should have a greater understanding of individuals rights and liberties. Staff had used the communication book to record safeguarding concerns in October 2009. It is not appropriate for such information to be recorded in this way. On the day of our visit staff were unable to provide clarification of whether a safeguarding referral had been made on behalf of this person or whether this issue had been discussed with other healthcare professionals Following the inspection the provider wrote to us with information about when referrals had been made for this person. Clear records need to be kept about safeguarding issues together with information about how decisions have been made and who has been involved in making those decisions. This will make sure that people are properly protected. Care Homes for Older People Page 21 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, comfortable and well maintained environment. Evidence: The manager wrote in the AQAA: The living environment in the Home is age appropriate. The Champion Unit environment is focused towards the younger age group who use that service. Not only this, but with the nature of the illness, clients have notices in their rooms for cues for their daily lives. Two of the bedrooms on the elderly side and two of the bedrooms on the Champion side have had new bedroom suites. The upstairs lounge on the elderly side and the Champion Lounge have been redecorated. Residents and/or their families are encouraged to bring in their own possessions in order to personalise their own living spaces. We have several members of staff who are on the Tackling Healthcare Acquired Infections outside of hospital programme. All of our staff are trained in infection control. The home is purpose built. All rooms are single and are en suite. In Champion Unit residents are involved in all household chores. This includes provision of evening meals. Improvements in the last 12 months: We have refurnished 4 bedrooms and decorated others. We have decorated the upstairs lounge in the elderly unit. We have decorated the lounge in the Champion Unit. We have provided a rehabilitation kitchen for the Champion Unit. We have provided a laundry room for the Champion Unit. We provide fresh fruit in the lounges. We provide fresh flowers or plants in the lounges. Care Homes for Older People Page 22 of 31 Evidence: We have provided a new DVD/CD player and DVDs that the residents chose for the downstairs unit on the elderly side. In discussion with some of the elderly residents we have purchased pictures of the rat packJames Dean and Audrey Hepburn for the corridor downstairs in the elderly unit. In addition to the ongoing refurbishment and improvements to the environment detailed in the AQAA there are plans for a major refurbishment of the home to be completed this year. At the time of our visit a fire safety inspection was being completed by West Yorkshire Fire Service (WYFS). Fire safety systems were found to be satisfactory overall, with some shortfalls which can be done as part of the overall refurbishment of the home. We visited all areas of the home used by the people who live there and everywhere was fresh and clean. We saw good control of infection practices used by staff. Care Homes for Older People Page 23 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are cared for by trained and competant staff. People are protected by safe recruitement procedures. Evidence: The manager wrote in the AQAA: We have a comprehensive Personel manual which contains all the tools neccessary for recruitment. This includes job descriptions, standard letters of acceptance/rejection. Invitations to interview if done in writing instead of being organised with the candidate over the phone. We endeavour to recruit the right person for the joband person centred approach is discussed at interviews for each post. We have a mixture of length of service for staff which enables us to avoid stagnation. All staff have completed their elearning and 26 of our staff have achieved NVQ2 or above. Ancillary staff are on programme for NVQ1. We have recently sent two of our staff to train as train the trainers in Manual Handling and they have begun their cascade training of the manual handling training programme. We have a robust probationary period for all staff. We keep interview notes and hold these on file. Minutes of staff meetings are held on file. Staff supervision is carried out regularly. We keep records of reasons for staff leaving. Improvements in last 12 months: All staff have now completed their elearning. We now have 2 train the trainers in manual handling. Supervision of staff is now more robust. Most of our staff have either achieved or are on programme for NVQs. Staff on the ARBI unit are on training programmes about ARBI residents. Care Homes for Older People Page 24 of 31 Evidence: We saw that there were enough staff on duty to look after people properly. Staff were visible in the lounge areas so that they were available to the people who spend their time there. Staff said that they feel well supported and have access to enough training so that they know how to care for people. training is done primarily through e-learning. This means that staff undertake training at their own pace at a time convenient to them. Records of training are clear and show that the majority of staff have completed mandatory training. We looked at the recruitment files for recently employed staff and found that all the required checks are completed for staff before they start work at the home. These files also included evidence that there is a formal supervision programme in place for care staff. Care Homes for Older People Page 25 of 31 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is inconsistency in the management of the service with some people not always receiving an effective service. Evidence: The manager wrote in the AQAA: The new Home Manager is suitably qualified and experienced for the post. The Home provides a care manual which informs staff in a step by step way as to how to improve their practise. Staff supervision includes the Philosophy of Care of the home and invites staff members to comment on how delivery of care within the home can be improved. The home has a clear management structure. The home has an up to date liability insurance. Residents monies are safeguarded and supported by the correct documentation and receipting process. We do not act as appointees for residents. Accidents are recorded and audited and if necessary a Regulation 37 is completed. Medication is stored, administered and recorded by competent personnel. Care plans are regularly audited. Home Manager holds regular resident/relative meetings. Home Manager is visible on the floor of the nursing home as much as possible. Home Manager randomly samples food to ensure it Care Homes for Older People Page 26 of 31 Evidence: is well presented, at the correct temperature, and tasty. Home Manager flexes her shifts so that she is not too predictable and is in attendance at the home at different hours on different days. Home Manager has turned up unannounced during the weekend to observe the home at the weekend. On other occasions she has informed staff that she will be in at the weekend but has not stated when. Improvements planned - To do spot checks on nights at least twice a year. Manager is awaiting CRB so that she can continue her application to register as manager with CQC Since the last inspection there has been another change of manager at the home. The current manager has been at the home since July 2009 and has not yet applied to be registered with us as manager. The manager is a qualified nurse and has previous experience of the management of a care home. People told us that she provided clear leadership and spoke highly of her commitment to improve the service. There is a regular system of audits in place to help the manager in the ongoing monitoring of the service. Satisfaction surveys are completed annually and the results are available to people in the service user guide. We looked at the results of audit and these were detailed and realistic about what needs to improve at the service. Staff, relatives and people living at the home are interviewed as part of this process. Action plans are produced as a result of the audits to address identified shortfalls. The required provider visits to the home are recorded and the format has been revised to make these reports more detailed and to give clarity on any action needed following one of these (at least) monthly visits. The manager meets regularly with staff and notes are kept of these meetings. Resident and relative meetings are also held on a monthly basis. The manager predominantly spends her time in the nursing unit and has successfully introduced changes that have improved the quality of care within this part of the home. The manager has not had as much involvement with the rehabilitation unit. The provider needs to review the way the Champion Crescent unit is managed to make sure that people are having their healthcare needs looked after by building up contacts with other healthcare professionals who might be able to support staff in caring for this client group. The provider also needs to make sure that there is enough support for the care staff who work in this specialised unit. Care Homes for Older People Page 27 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 28 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 Decisions should be made through a formal decision making process which fully involves the person who uses the service and/or their representative. People should have access to a wider range of healthcare services to make sure they receive the right support during their rehabilitation programme. Information about peoples care needs should be kept together in individual files. This is to make sure that staff have access to all the information they need to know how to look after someone properly. Staff need more input from management on when to seek guidance from the local authority safeguarding team. This is to make sure that people are safeguarded. There should be clear evidence available to show how safeguarding decisions are made and who has been involved in making those decisions. This is to make sure that people are protected. 2 8 3 8 4 18 5 18 Care Homes for Older People Page 29 of 31 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 6 31 The manager should make her application to be registered as soon as possible. This will mean that the home will have a suitable person in day to day control. The manager should be have more involvement in the day to day running of the dementia unit to make sure the service as a whole is meeting the homes aims and objectives. 7 31 Care Homes for Older People Page 30 of 31 Helpline: 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. Care Homes for Older People Page 31 of 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!