Inspection on 13/02/07 for Glen Rosa & Kitwood House

This inspection was carried out on 13th February 2007.

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

Other inspections for this house

Glen Rosa & Kitwood House 19/01/09

Glen Rosa & Kitwood House 08/02/06

Glen Rosa & Kitwood House 13/07/05

Glen Rosa & Kitwood House 23/12/04

Glen Rosa & Kitwood House 01/07/04

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

CARE HOMES FOR OLDER PEOPLE Glen Rosa & Kitwood House 24 Grove Road Ilkley West Yorkshire LS29 9PH Lead Inspector Chris Levi Key Unannounced Inspection 13th February 2007 09:15 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 Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 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. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glen Rosa & Kitwood House Address 24 Grove Road Ilkley West Yorkshire LS29 9PH 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) 01943 609604 01943 817363 home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Susan Sullivan Care Home 47 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (33), of places Physical disability over 65 years of age (3) Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2006 Brief Description of the Service: The home is owned and run by Methodist Homes for the Aged a national voluntary organisation. Glen Rosa and Kitwood House are situated on Grove Road in Ilkley, close to the town centre and public transport. The house is situated in large, well-maintained grounds and gardens that provide for ample car parking. The main building is a period property that has been converted and extended and now provides accommodation for thirty-three older people. The extension, Kitwood House has been built for the purpose of providing care to 14 older people with dementia. There is ramped access to the side of the building to provide access for those using mobility aids. Weekly charges are £435 to £525 at the time of this report. The Inspection report is displayed in the ground floor communal area. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Evidence used to compile this report has included: Information requested from the providers in a Pre-Inspection Questionnaire A review of information about the home held by the Commission for Social Care Inspection. This included looking at the number of reported accidents, complaints and compliments from residents and relatives. This information was used to plan the inspection visit. The written and verbal opinions of residents and relatives who live and visit Glen Rosa & Kitwood House. The providers were not notified of this inspection in advance. This enabled the inspector to observe how the home is run on a day-to-day basis, without any changes being made to the usual routines of residents and staff. The visit started at 9.15am and finished at 4.30 pm. The person in charge of the home was the Manager Mrs Sullivan, who was made aware of the findings at the end of the inspection. Most of the day was spent talking to residents, relatives, management and staff, to find out what it is like to live, work and visit Glen Rosa & Kitwood House. Ten residents survey forms were sent out before the visit. Two were returned and contained positive comments about the service. In addition a further five were distributed during the visit, for residents to complete at a later date What the service does well: Glen Rosa & Kitwood House is a well managed, friendly home. Staff work hard to give residents a good quality of life, by maintaining their independence, supporting them with their care and health needs, and providing an interesting place to live. The home is owned by MHA. a not for profit organisation. Although founded on Methodist values, the home welcomes both residents and staff from different cultures and religions, and has successfully created a culture of respect for the individual. Staff recruitment and training is thorough, to ensure staff are skilled to provide support and care to vulnerable older people. The staff are well organised. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 6 They are experienced, know what they are doing and have a good knowledge of the residents they care for. They have good relationships with residents and relatives. Relatives feel welcome at the home. There is a warm and supportive atmosphere in the home. The standard of information available to people who are considering living at Glen Rosa & Kitwood House is excellent, and should help people decide if this is the home they want to move to. The quality of environment is excellent. Each resident has their own room with en-suite facilities and access to a number of communal lounges around the home. What has improved since the last inspection? What they could do better: Residents said they would like more activities. One commented, “not enough goes on here”. The home is introducing a new model of recording care planning. When complete, the documents will hold comprehensive information about the individual resident, thus enabling staff to provide a person centred focus of care. However, few of these care plans are complete and previously held information has been removed. This may result in important information, relating to the needs of a resident being missed, and the resident suffering ill effects. The manager should consider if the current target date for completion of the new system is achievable, without compromising the quality of information necessary for good care planning that accurately reflects the needs of the residents. The home is very clean and tidy but areas of cleanliness in the kitchen need to be improved to ensure residents are not at risk from cross contamination. The laundry should be locked when not in use to minimise the risk of injury or incidents to residents, who can currently enter the laundry from the main corridor. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 7 The current practice, observed at lunchtime, where two members of staff are involved in administering medication to residents in the dining room is unsafe, and may result in residents receiving the wrong medication causing them harm. 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. The summary of this inspection report can be made available in other formats on request. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 8 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 Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides excellent information for residents and/or relatives to make an informed decision about the home before they move in. Comprehensive pre admission information obtained by the manager and staff ensures that there is an understanding of individual needs of residents, before they move to the home. EVIDENCE: Written information about services at the home is available to anyone interested in moving to Glen Rosa & Kitwood House. It gives the reader clear, detailed information in a range of documents. These include a Statement of Purpose, and Service User Guide.They were up to date with relevant information about services provided at the home. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 10 All residents are visited and their care needs assessed before they move to the home. This is completed by the manager or senior member of staff. Prospective residents are encouraged to visit and talk to staff and residents. The pre- admission records are thorough, and provide information to staff about the care needs of the individual when they move to the home. Two pre admission assessments were looked at, both appeared to accurately reflect the needs of the residents. All residents are given a contract of residency. It gives details of responsibility of both the owners and the residents whilst living at the home. It also states the weekly fees charged by the owners. These documents were seen during the visit. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social needs of residents are met, in a way that maintains their dignity and independence. EVIDENCE: Three care plans were looked at. These were only partially complete as the home is implementing a new format for recording the needs of individual residents. Because staff are completing these new plans with a target date for completion of March 2007, some information, necessary to the resident’s well being was not recorded. The old care plans, containing information about the residents’ needs, have been removed. This may be putting residents at risk of harm. The manager should review the process of introducing the new plans to ensure relevant information about residents is available and up to date. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 12 One almost complete plan, had excellent information about how the needs of the resident would be met and there was evidence that the resident had been very involved in identifying their needs. Residents with low weight should be weighed weekly, and records of the weights easily accessed, to ensure their health needs are being met. There was evidence that external health professionals provide an effective responsive service to meet the health needs of residents at the home. These are recorded within the individual care plan. The home has a very thorough medication procedure, and all staff are trained to administer medication safely, to ensure the resident receives the correct medication at the time prescribed by the doctor. A senior member of staff was observed giving residents their lunchtime medication. The procedure involved two members of staff administering the medication. This is unsafe practice and could result in a resident receiving the wrong medication, which may affect their well being. Medicines are stored safely, and checked to ensure they are correct when they arrive from the pharmacist. The procedure for the management of controlled drugs is safe. Comments made by residents and the observations made of staff practice show that staff treat residents with sensitivity and respect. Without exception the views expressed by residents and a relative indicated that staff are very caring and the relationships were very warm. The manager has introduced a system to obtain residents views about how they would like to be cared for in their final days of life. This will provide staff with sensitive information, before it is needed to be put into practice. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are part of the local community, spending their day as they choose, seeing whom they choose, when they choose. EVIDENCE: In discussion with residents and relatives, it was clear that staff encourage residents to live their lives as they wish within the care home. One relative said, “I am so thankful my mum is living here. Staff are wonderful and make me feel welcome when ever I visit.” A number of residents commented they would like more to do, and a discussion with the manager identified that the social activities programmes need to be reviewed, to meet the needs of all residents in the home. The cook was on holiday during the visit, so, a senior member of the care team was cooking until her return. The menus were looked at and choices are available at all mealtimes. Lunch was observed at Kitwood House. Staff, to ensure the residents had no distraction whilst lunch was served, created a Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 14 calm atmosphere. The senior carer demonstrated good practice by showing the residents, who have dementia, the choices of food available for lunch. Staff offered to assist residents, when required, in a sensitive manner. The kitchen was generally clean and tidy, with the exception of the cooker that would benefit from a specialist clean, and fridges that were grubby. Residents said they enjoyed the food served at the home. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can complain, and all staff are trained to ensure they understand adult abuse, to protect residents at the home. EVIDENCE: The home has a complaints procedure in the hallway. Residents and visitors said they would complain if they needed to. A book to record complaints was seen. Four complaints were recorded appropriately and the complainants satisfied with the outcome. Staff have received training in understanding, recognising and reporting abuse, which may put residents at risk of harm. Evidence of this was seen in two staff files, and confirmed in conversations with staff. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home that is safe, well maintained and of a high standard. EVIDENCE: Residents value the fact they all have single rooms with en-suite facilities to help them maintain their independence, and dignity. Communal areas in the home allow for residents to spend time in a number of different lounges throughout the house. A number of residents rooms seen were highly personalised, with items of furniture and pictures from their own homes. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 17 The home must supply bedding unless a resident chooses to buy their own. At Kitwood House the residents have access to an enclosed garden to encourage them to spend time outside safely. Colour coordinated doors and icons and photos are also used to help the residents identify where they are in the building. Despite the fact that there is a vacancy for a domestic, the house is clean, tidy and free from odour. Care staff are currently assisting with cleaning duties at Kitwood House, until a domestic can be recruited. The laundry should be locked when not in use to minimise the risk of injury or incidents to residents, who can currently enter the laundry from the main corridor. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The procedures for the recruitment, training, and deployment of staff is thorough and protects people living in the home EVIDENCE: The number of staff on duty was appropriate to meet the current needs of the residents. The recruitment file of one member of staff was looked at. It contained all relevant information, with evidence that references and police checks had been completed before she commenced employment, to ensure she was fit to work with vulnerable adults. The induction programme for new staff is comprehensive and the management team makes checks that staff understand the training they have received, before they work alone with residents. Staff said they enjoyed the extensive training they received, and felt it helped them to provide good levels of care to residents. All staff are offered the Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 19 opportunity to undertake a care qualification to help them develop good care skills. 65 of care staff have achieved a formal care qualification. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Glen Rosa & Kitwood House is a very well managed home, where residents and staff feel valued. EVIDENCE: The home is owned by MHA. A not for profit organisation. Although founded on Methodist values, the home welcomes both residents and staff from different cultures and religions, and has successfully created a culture of respect for the individual. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 21 The manager, Mrs S Sullivan, has many years experience working for the organisation, and has recently completed an academic management qualification the Registered Managers Award. This should complement her existing skills and knowledge to manage a large diverse service. The organisation has twice yearly quality monitoring systems that include the views of resident’s, staff, and others involved with the home. These audits are analyzed and changes made to the service where appropriate. It was suggested that the finding be published and issued to those people who took part in the process, to increase the sense of inclusion about decision making in the home. Any residents’ monies held at the home is managed in a safe way, with evidence as to who, and how, residents monies is spent. Relatives are encouraged to manage the financial affairs of any resident unable to manage their own money. Staff continue to receive regular one to one supervisions at least six times a year. Evidence of this was seen and one member of staff said she found them very useful to discuss her performance and training opportunities. The home has very thorough health and safety checking systems in place, to ensure the safety and well being of anyone in the building. The maintenance person has responsibilities for checking the hot water to ensure no resident is at risk from scalding. Documents sent to the inspector before the visit indicate that all maintenance and servicing of equipment used in the home has been serviced, and is safe to use. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 22 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 4 3 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 4 x x 4 4 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 x 3 3 x 3 Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The manager must ensure the practice of administration of medication by staff to residents is safe. Timescale for action 30/03/07 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 3 Refer to Standard OP38 OP12 OP7 Good Practice Recommendations The kitchen cooker should be deep cleaned and fridges cleaned. The laundry door should be locked when not in use. The manager should review the current level of social activities with the aim to increase them as identified by residents. The manager should review the target date for the implementation of all new care plans to see if it is realistically achievable. Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Glen Rosa & Kitwood House DS0000001243.V326384.R01.S.doc Version 5.2 Page 25 - 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!