Inspection on 18/05/06 for Kirkley Manor

This inspection was carried out on 18th May 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 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

Kirkley Manor 23/07/08

Kirkley Manor 24/07/07

Kirkley Manor 20/10/05

Kirkley Manor 29/04/05

Kirkley Manor 21/10/04

Kirkley Manor 20/05/04

Kirkley Manor 19/11/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Kensington House Nursing and Residential Home 3 Kirkley Park Road Lowestoft Suffolk NR33 0LQ Lead Inspector Mike Usher Key Unannounced Inspection 18th May 2006 11:00 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 Kensington House Nursing and Residential Home DS0000040035.V295978.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. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kensington House Nursing and Residential Home Address 3 Kirkley Park Road Lowestoft Suffolk NR33 0LQ 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) 01502 573054 01502 513862 debbie@kingsleycarehomes.com Kingsley Care Homes Ltd Ruth Anne Stannard Care Home 70 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (54), of places Physical disability (5) Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th October 2005 Brief Description of the Service: The home is registered for 70 service users in 50 single rooms and 10 shared rooms. Of these, 44 rooms have en-suite facilities. The home has grown up around the original large Edwardian house, and is set in well-tended grounds, to the front and rear. The provision of accommodation is suitable for older people with mobility problems, with appropriate aids and adaptations fitted, although the shaft lift is not modern - being fitted with a heavy, hand-operated outer door, and an internal iron grill cage door. Consequently, some service users may find this difficult to manage on their own. A newly built, self-contained dementia care unit has been added to the rear of the home, and provides modern, comfortable accommodation for 16 persons with dementia. In addition, the main building can now accommodate up to 5 persons with dementia, who require nursing care. The home has an experienced manager, and at least one nurse is on duty at all times. There is a competent team of care staff, assisted by a full complement of ancillary workers. The home is operated by Kingsley Care Homes Ltd, which owns a number of other care homes in East Anglia. The company Directors are regularly on the premises, as is the Operations Manager. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection focused on core standards, previous requirements and recommendations, and recent developments. It utilised previous correspondence and documentation, feedback from service users and relatives, observation of staff practice, and discussion with managers, staff, service users and relatives. In addition, various procedures and policies, and essential records were inspected. The Commission has now registered the manager, and further changes to the home’s registration have seen the provision of nursing care for a small number of people with dementia introduced. The home has continued to improve the quality of the service provided, and this reflects the owner’s commitment to raising standards, and a continued investment in all aspects of the home’s operation. What the service does well: What has improved since the last inspection? The new manager has been registered, and has established herself at the home, and a post of Deputy Manager has been created and is being recruited to. This substantially strengthens the home’s first line management. In addition, the owner’s quality assurance system continues to improve and is beginning to prove effective and robust. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 6 Consequently the number of complaints and concerns raised with the Commission has greatly reduced, with the company proving more effective at dealing with complaints appropriately. A new training unit has been established by the owners, based on site at Kensington House. This will enable the company to deliver a comprehensive training programme to all staff. The environment continues to improve with a continuing programme of maintenance and refurbishment in place, as well as specific developments such as the division of the rear lounge into smaller, more intimate areas of seating. New documentation has been introduced to assist prospective service users, and to reflect the recent changes in provision. New care plans are being introduced to simplify the process and to allow easier access by staff and service users. Standards of hygiene in the home are very good, with the home coping well with a recent outbreak of illness among staff and residents. 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. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 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 Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 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, 4 The home provides adequate information to prospective service users, and has suitable procedures to ensure that their needs can be met. The home does not offer intermediate care, and therefore NMS 6 is not applicable. EVIDENCE: The home’s Statement of Purpose and the Service User Guide have recently been updated to reflect the recent changes, and copies supplied to the Commission. These are now available to service users. The manager ensures that an initial assessment is carried out, and incorporates any previous assessment provided by health or social care services. The assessment covers all essential areas, including moving and handling issues, and risk. A social care assessment is also included. This is usually completed by a close relative of the service user, thus ensuring that a good amount of background information, and personal preferences, is well known to the home on admission. Assessments are signed off, and there was evidence that they are regularly reviewed. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 9 Service users and relatives consulted during the inspection process confirmed that they were satisfied that the home could meet their needs prior to admission. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 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, 8, 9, 10 Service users’ health and personal care needs are met through their plan of care. Medication arrangements are generally satisfactory but attention to detail is required. Issues of privacy and dignity are generally well recognised and dealt with sensitively, with minor exceptions. EVIDENCE: Information relating to care plans is located in paper files and on the home’s computer system. Combined with the needs assessments and risk assessments, this represents a reasonably comprehensive approach, although social/emotional matters were less detailed. Relatives consulted during the inspection confirmed that they are kept well informed regarding residents’ care, and are involved in care planning and reviewing. The current care planning arrangements are somewhat complex, and the management are planning to introduce a simpler system that is easily accessible to all staff, and based on a written care plan that will stored in service users’ bedrooms. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 11 An examination of the arrangements for the storage and administration of medicines found these to be generally in good order, with some minor shortfalls. The medication is dispensed from two professional medication trolleys, which were appropriately secured. A Monitored Dosage system is used, supplied by a local pharmacy. Records were clear and in good order, although some examples were found of erroneous record entries. Examination of the storage and recording for controlled drugs found this to be satisfactory. The home maintains close contact with local health professionals, and on the day of the inspection a GP was visiting a service user, having been asked to visit by staff. In discussion with service users, staff and managers, and by observation, it was established that issues of privacy and dignity are given a high priority. Staff were seen to attend to the personal care needs of residents in an appropriately sensitive manner, although one resident was observed to spend some time sitting in a wheelchair in the corridor waiting for the WC to be vacated. This may be indicative of an inadequate provision in that part of the home, but that should not result in residents being ‘queued’ in the corridor outside. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 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, 15 The home provides a variety of activities and entertainments for residents, and there is a constant flow of visitors throughout the day. Service users were satisfied with the catering arrangements, and are offered a choice of menus. EVIDENCE: The home has a programme of social and therapeutic activities, and entertainments, that are posted in hallways and on notice boards. On the day of the (unannounced) inspection, residents gathered in the dining room to be entertained by a visiting disc jockey specialising in music from the 1950’s. Other activities provided on a regular basis include quizzes, games, exercise and therapy, and the pat-a-dog service. Funding is now being provided to hire a wheelchair accessible mini-bus on a regular basis for trips out, in addition to a ‘people carrier’ vehicle which is available at all times for residents’ use. Links with the local community are supported by the welcome extended to visitors and relatives, a good number of who were visiting during the inspection. Several visitors were spoken with during the inspection and they were generally very positive about the standard of care provided. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 13 A set of menus are displayed in the dining room, and residents’ meal choices are canvassed each morning by care staff. There is always a choice of main course available and those relatives and service users spoken with felt that the standard of catering was very good. The dining room is close to the centre of the home and other communal areas, although it was noted that some residents were seated at the dinner table more than 45 minutes before lunch was served. This aspect of daily life should be reviewed to minimise such waiting time. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 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, 18 The home operates an effective complaints procedure and service users are safeguarded by the home’s training and procedures. EVIDENCE: The home has an appropriate complaints procedure in place, and responds very actively to any expression of concern. This has been demonstrated in recent months with the managements handling of two formal complaints. In both cases, an investigation was undertaken by senior managers (in one case involving an external consultant) and where shortcomings were identified, action was taken to address these. The Commission was copied into correspondence, and provided with copies of reports, so that this process could be monitored. In the past the home has often struggled to adequately respond to concerns raised by relatives, but with the new manager in post, and an increased commitment from senior managers, the number of concerns reported to the Commission has greatly reduced, and the actions taken in response by the home have been more effective. Recently this has resulted in the installation of a direct phone line to Kingswood unit, to facilitate contact with relatives. Staff benefit from appropriate training in abuse awareness, and other training designed to protect and safeguard service users. Management are aware of local Protection Of Vulnerable Adult (known as POVA) Procedures, and work closely with local Social Care Services staff to monitor standards within the home. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 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, 21, 23, 24, 26 The accommodation is well maintained with good standards of hygiene throughout the home. Bedrooms and communal areas are comfortable and homely. EVIDENCE: At the time of the inspection, work was in progress to divide the large lounge at the rear of the building, to provide smaller, more intimate, communal areas for residents, including those with dementia. The building work was being well confined in terms of disturbance, although this inevitably meant that other communal areas were more crowded than usual. In general the home is being well maintained, with communal areas being kept in good repair and adequately furnished. New carpeting is planned for the ground floor corridors. A continuing programme of repair and refurbishment is in place, and the management are actively considering how the accommodation may be further improved. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 16 Bedrooms are comfortable and well furnished, and residents are able to personalise them to their personal taste. Provision of bathrooms and WC’s is adequate, as previous inspections have established, but the current arrangements should be reviewed in line with the comments earlier in the report (see under NMS 10). During a tour of the home it was noted that bathrooms and WC’s were clean and well stocked with soap and paper towels. Alcohol hand cleanser dispensers were sited on walls throughout the building, encouraging staff to cleanse their hands frequently. However, it was also noted that a number of bathrooms and WC’s were being used to store wheelchairs, hoists and walking frames. It would also promote a more homely atmosphere in bedrooms if suitcases and incontinence pads could be stored out of sight. Just before Christmas the home suffered from an outbreak of winter vomiting, a highly contagious form of diarrhoea and vomiting. The management responded appropriately, involving the local health service infection control service, and the outbreak was contained and eliminated. The infection control nurse commented that the home had dealt with the outbreak very well. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 17 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, 29, 30 Service users needs are met by a competent and well-trained staff team. The home’s recruitment procedures are satisfactory. EVIDENCE: On the day of the (unannounced) inspection, there were 7 carers and 2 nurses on duty in the morning, and 5 carers and 2 nurses on the afternoon shift. The night shift would have 3 carers and one nurse on duty. This is currently the planned staffing level for the number of residents (63). The morning and afternoon shifts will have an additional carer on duty when the number of residents rises above 63. Then home employs a number of staff from Eastern Europe, mostly Polish, and these staff make a significant contribution to the home. Residents and relatives consulted during the inspection were very happy with the standard of care provided by all the staff, and were very positive concerning staff from abroad. The home takes great care to ensure that staff from abroad have adequate communication skills, and staff are required to speak in English at all times whilst on duty. This is a positive aspect of management, designed to ensure that residents and relatives do not feel excluded from conversation at any time. The management of the home is being strengthened with the appointment of a Deputy Manager from June 2006, with a remit to improve links between staff, the home, and relatives. The Deputy will be supernumerary to the current level of care staffing. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 18 Kingsley Care Homes has recently set up its own training company, which is based at Kensington House. This will ensure that appropriate training is accurately targeted, and current priorities are ‘Train the Trainers’ courses, and NVQ Assessors. In addition, dedicated management training will commence in June to ensure that all management staff maintain their own training and development. It was possible on the day of the inspection to speak with a member of the Training team, and they confirmed that all staff have completed mandatory training, and that all staff are either undertaking, or have completed the National Vocational Qualification (known as NVQ) at Level 2. In addition, 5 carers have achieved the Level 3 award. The Training team is currently drawing up a comprehensive training programme based on individual personal development plans (a sample of which was seen). An examination of the home’s recruitment procedures found these to be in good order. All staff files now contain a photograph and other proof of identity. Survey forms were left with the management to be distributed to all the staff on duty on the day of the inspection. The results of this survey will be incorporated into the next inspection. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 19 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, 36, 37, 38 The owners have established an effective management of the home and the standard continues to improve. EVIDENCE: The manager of the home has been registered by the Commission. They have been in post for some months now, and it was evident from this inspection that the management of the home is becoming more effective, and improving the standard of care provided. The management of the home have recently conducted an extensive quality review of the service and a copy of the resulting report has been supplied to the Commission. An analysis of the results indicates a good level of satisfaction with the service. A further review will be conducted in June 2006 that will focus on the views of wider stakeholders as well as service users. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 20 The company now has a comprehensive service monitoring system in place, and is introducing an internal inspection audit process in the next few weeks, in addition to the current visits required by regulation. The manager confirmed that the home does not, as a matter of principle, handle money on behalf of service users. On occasion, the home may agree to safeguard small amounts of cash and minor items of value, for service users, and appropriate storage is available, and receipts are issued. Essential records examined during the course of the inspection were in good order (subject to minor shortfalls in medication records – see under NMS 9), and effective management systems have now been established to safeguard service users. Regular staff meetings are held (minutes seen) for all staff, and with senior staff and nurses. Essential information is often distributed to staff by including memos with staff pay packets, ensuring that it is received. Effective staff supervision is established, and the management’s commitment to high standards is evidenced by recent dismissals of staff members for poor practice. Fire safety is now the responsibility of the Support Services Manager, who completes the fire risk assessments now required by regulations, and also supervises the checking of fire safety systems, and fire drills. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 21 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X 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 3 X 3 3 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 2 3 Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 22 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 OP37 Regulation Schedule 3 3 (1) Requirement All records must be accurate. Timescale for action 18/05/06 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 OP10 OP21 OP22 Good Practice Recommendations Care practice should be reviewed to ensure that residents are not waiting unnecessarily long periods for meals or use of the toilet. The adequacy of the provision of WC’s near the rear lounge should be reviewed. The storage of equipment should be reviewed to ensure that it does not obstruct the use of bathrooms and WC’s. Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Kensington House Nursing and Residential Home DS0000040035.V295978.R01.S.doc Version 5.2 Page 24 - 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. 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