Inspection on 03/01/06 for Bury Metro - Killelea

This inspection was carried out on 3rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bury Metro - Killelea 07/09/06

Bury Metro - Killelea 04/07/05

Bury Metro - Killelea 14/03/05

Bury Metro - Killelea 27/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bury Metro - Killelea Killelea Residential Care Home Brandlesholme Road Bury Lancs BL8 1JJ Lead Inspector Rukhsana Yates Unannounced Inspection 3rd January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bury Metro - Killelea Address Killelea Residential Care Home Brandlesholme Road Bury Lancs BL8 1JJ 0161 253 6550 0161 252 6551 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) Bury M.B.C. Mrs Marie Josephine Glynn Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (1) of places Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 36 service users, to include: up to 35 service users in the category of OP (Older People) up to 1 named service user in the category of PD (Physical Disabilities under 65 years of age) may be accommodated within the overall number of registered places. The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. The service must at all times employ suitably qualified and experienced staff to meet the assessed needs of service users. Within the maximum of 36 places registered, there is provision for up to 18 places for intermediate care. 4th July 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Killelea House provides a range of services to older people in the Bury area. These include Intermediate Care, the aim of which is to promote recovery, independence and daily living skills for people who may then be able to return to live at home following an illness or accident. The remaining places provide Short Stay Care, Interim Care, and a limited number of permanent residential care places. The home has undergone major refurbishment to create a purpose built facility. There are two floors with lift access. All bedrooms are single and have en-suite facilities. Killelea is situated one mile from the centre of Bury and is on a main bus route. Details of the services at Killelea are described in a Statement of Purpose which is available on request. Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and carried out over 7 hours. Most of the tome was spent talking to permanent, short stay and intermediate care service users. Discussions took place with health staff involved in supporting service users with their independence programmes, with care staff, and with relatives of service users. The inspection also included attendance at two service user review meetings. Some time was spent watching the way in which staff provided support, and looking around the home. Some paperwork relating to the care and safety of service users was examined. What the service does well: What has improved since the last inspection? As a relatively new service in a completely refurbished building, staff had reported some “teething problems” at the last inspection, and felt that the service is now adapting to this new base, and teamwork has been developing well. Service users commented on the improvement in the quality of meals since the last inspection. At the last inspection, it was felt that there were not enough staff to cover both floors effectively. Some changes have been made to address this. For example, service users from both floors are encouraged to use the main dining room on the ground floor for dinner, although they do have a choice of where to eat. Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 7 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 Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Service users admitted to Killelea House have their needs assessed and are given information about the home to ensure the service provided is suitable. Intermediate care service users benefit from a good range of support to maximise their independence. EVIDENCE: There is a statement of purpose and a service users’ guide to the home. Both of these documents clearly describe the services provided, the criteria and process for admission, review arrangements, along with a range of other useful information for residents and their relatives. The documents are readily available to the users of the service. Care files showed that each person has their needs assessed before admission. The home ensures that a community care assessment is obtained, and a multidisciplinary assessment carried out if necessary. The major refurbishment of Killelea House has taken account of the facilities needed to provide an effective intermediate care service. Facilities include a Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 9 Physiotherapy room, Occupational therapy room and a fully equipped therapy kitchen. The care plan for each person is based on the input of a multidisciplinary team that includes trained care staff, physiotherapists and occupational therapists, district nurses, consultants and social workers. Care plans reflect the support given to enable people to return home, and the service users’ involvement in reviewing their own progress. Discussions with service users confirmed that they knew about the aims of the service, and were pleased with the support. The home is in the process of analysing referrals and discharges to assess whether the service is being used appropriately, that is, for service users with the potential to regain independence in their own homes. The need for this was highlighted during this visit in terms of highly dependent service users with dementia inappropriately referred for intermediate care. Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10 Each service user’s personal, health, social care needs and risk assessments are reflected in their care plan. Regular reviews ensure that changes in need are known and effectively met. Medication procedures are safe. Service users feel their rights to privacy and respect are upheld. EVIDENCE: For those service users admitted for intermediate care, assessment information was up to date and being reviewed frequently by the multi-disciplinary team. Rehabilitation plans were clear in terms of goals and inputs required to achieve those goals. Plans were realistic, taking account of the risks associated with mobility and other activities of daily living. It was apparent that service users are involved in review meetings. It was suggested that review information provided to service users be made available in large print and plain language. The residents in the permanent stay beds have well devised care plans. Aims and actions relating to each area of need are specific, and cover a range of areas including sight / hearing, personal care, mobility and dexterity, family involvement, communication, social interests, mental state and cognition, religious and cultural beliefs, personal safety and risk. All areas are reviewed Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 11 each month. All service users consulted said that care staff treat them with respect and are polite. They felt that single rooms with en-suite facilities gave them the privacy they needed. Staff were seen to be discreet and to preserve service users’ dignity while assisting with personal care. Medication procedures appeared satisfactory although this standard was not assessed in detail. The home has regular visits from a pharmacist, and a CSCI pharmacist inspection is to be carried out later in the year. Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Service users feel they have flexible daily routines, are enabled to exercise choice, and helped to maintain links with family and friends. Some service users feel they need an increase in the number and range of social activities and interaction to enjoy their time at the home. Service users enjoy their meals and feel there has been a big improvement in meals since the last inspection. EVIDENCE: Residents said they have a choice in their daily routines, including what time they get up and go to bed. They also make decisions about where to spend their time during the day. In terms of activities, intermediate care clients are assisted to participate in rehabilitation programmes in line with their care plan. Organised recreational activities are limited at present as there is a vacancy for an Activities Coordinator. The home is in the process of recruiting to this post. Care staff carry out some activities if time and circumstances allow, and residents recently enjoyed carrying out craft activities with a visiting organisation, “Art to Heart”. The home has open visiting arrangements, and visitors described a welcoming atmosphere and helpful staff. Visitors have also been able to stay overnight if their relative has been unwell. The home tries to maintain links in the community through day trips and small scale shopping trips. Communion takes place regularly for residents who wish to participate. Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 13 Residents reported an improvement in the quality of the meals since the last inspection. The improvement is also evident from examining the home’s complaints records. The improvement has come about with more stable staffing arrangements in the kitchen and the return of the regular cook. Choices are offered at mealtimes, and the cook is made aware of the dietary needs of anyone newly admitted to the home. The kitchen was clean and well organised. The main dining room is used by most service users, but they may eat in their own rooms if they wish. Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents and their relatives feel able to air their views, and feel that that the manager and staff will listen and respond to their satisfaction. Written guidelines and staff training help to ensure the protection of residents EVIDENCE: Killelea has a written complaints procedure included in the service users’ guide. The procedure describes the stages and timescales for complaints and provides the contact details for the CSCI and for Bury Social Services. Service users consulted said that they, or their relatives, had been given the guide and they would speak to the manager or staff in the first instance if they had any issues. The home has regular residents’ and relatives’ meetings. There is a record of complaints and the action taken to resolve them. It was clear from the records, and from discussions with service users, that complaints are taken seriously, investigated, and the appropriate action taken. The home is making good progress to further staff members’ understanding of abuse and protection issues. The department is using a training pack that can be used by senior staff to train other staff at the home. The resource provides exercises and workbooks enabling the home to tailor learning to specific groups of staff. Understanding of the elements of training is then checked through individual discussions in supervision meetings, and there was evidence of this in the supervision records seen. Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Killelea provides a clean and comfortable environment for service users. EVIDENCE: Service users made positive comments about the environmental standards in the home. Accommodation is on two floors, with 18 single rooms on each floor. All bedrooms have en-suite facilities. The first floor bedrooms are for intermediate care service users, and there is sufficient communal and dining space available for all service users accommodated. Some bedrooms have tables that service users can use for their meals should they choose to eat in their rooms. Tables are being purchased for rooms that do not currently have them. Fire safety checks are carried out at the required intervals and records of checks maintained. Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 29 The staff group has the knowledge, skills and training needed to understand the care needs of residents. Staff numbers are adequate to ensure that personal care needs are met. Recruitment procedures include the checks necessary to help ensure the safety of residents. EVIDENCE: Training arrangements are very good. Over half of the care staff are qualified to NVQ level 2 or above. New staff members benefit from a comprehensive induction programme, and all staff attend mandatory courses. Carers working with intermediate care clients have completed specialist Diagnostic and Therapeutic NVQ training, and further relevant courses are being identified, such as management and risk assessment training. There are two carers on each floor during the day, with an additional carer helping out on both floors. Staff on the ground floor reported that the ‘floating’ staff member is usually on the first floor, leaving two to care for everyone on the ground floor most of the time. Some reorganisation, for example encouraging service users to use the main dining room, has helped to alleviate some of the problems this has caused, although service users would benefit from having a minimum of three carers on each floor during the day. All recruitment takes place via the Human Resources department. The recruitment process includes criminal record and related background checks, Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 17 and two references are obtained prior to a post being offered. The CSCI carries out an annual check of the authority’s recruitment procedures during which staff files are sampled for all residential homes within its remit. Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Service users and staff feel the home is well managed. The home is making good progress in monitoring the quality of the service it provides. Systems are in place to ensure that residents’ finances are safeguarded. Regular checks and tests ensure that residents live in a safe environment. EVIDENCE: There are clear lines of accountability within the home and with external management. The manager is very experienced in managing intermediate care and has achieved that Registered Managers Award. Staff and service users commented on the approachability of the manager and expressed confidence in the way the service is managed. Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 19 With regard to a quality assurance system, a survey has recently been carried out to ascertain the views of service users and others about various aspects of the home and their level of satisfaction with it. An action plan now needs to be devised that shows how these views are going to be used to improve the service. Each service user has a safe in their room to secure their personal monies, and is provided with a key if they want to take responsibility for it. Accurate record keeping and safe storage arrangements ensure that service users’ monies are properly managed and accounted for. Current certificates were seen in respect of gas, electrical, lift and portable appliances safety in the home. Staff at the home receive training covering health and safety issues. Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 20 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 3 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP12 Regulation 13, 16 Requirement Timescale for action 31/05/06 2 OP33 24 The registered person must ensure that the social and recreational needs of each resident are assessed and met within a suitably resourced activity programme. (previous timescale of 03/10/05 not met) The registered person must 31/03/06 produce an quality improvement action plan based on the views of service users and other stakeholders. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP7 OP19 Good Practice Recommendations Assessment and review information for service users should be made available in large print and plain English. A small table should be provided in each bedroom. Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bury Metro - Killelea DS0000008465.V275382.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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