Inspection on 20/10/05 for Kirkley Manor

This inspection was carried out on 20th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 18/05/06

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 Announced Inspection 20th October 2005 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 Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 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.V254112.R01.S.doc Version 5.0 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 Post Vacant Care Home 70 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (54), of places Physical disability (5) Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th April 2005 Brief Description of the Service: The home is now 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 new extension has been built on the rear of the existing building, which is specifically designed to care for people with dementia, and has been finished to a very high standard (see details within the report). The home has recently appointed a new 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.V254112.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection focused on progress regarding previous requirements and recommendations, significant developments, and management issues. The inspection used observation, examination of records and other documents, discussions with management, staff, and residents, and made use of information provided by the home prior to the inspection visit. A large part of the inspection was concerned with looking at the new extension to the rear of the existing home, which is to provide specialist care to people with dementia. Detailed discussions were held regarding how this unit will operate, and a large amount of information and relevant documentation was supplied by the owners prior to, and during, the inspection. What the service does well: What has improved since the last inspection? A new manager has been appointed, and the management further strengthened and expanded to focus on improving the quality of the care provided. Training has grown to focus on caring for the needs of people with dementia, in anticipation of the new dementia care unit opening. The use of specialist advisers, trainers and consultants has enabled the management to concentrate on introducing new care practices throughout every level of the homes operation. This primarily focuses on the development of person-centred care for people with dementia, but is intended to extend this approach to care within the whole home. The new extension has been completed to a very high standard and has been specifically designed to provide safe and comfortable accommodation for people with dementia, that is also a therapeutic environment. A new staff team has been created to run the new unit. Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 Page 6 The maintenance of the existing building has improved and the home was noticeably fresher and brighter. New communal areas have been created to provide more choice and variety for service users. Quality assurance processes have been further developed to provide a more effective and responsive service. The management were able to respond immediately to a number of issues discussed during the inspection (see below). 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.V254112.R01.S.doc Version 5.0 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.V254112.R01.S.doc Version 5.0 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 New quality procedures and documentation have been developed to meet the needs of people with dementia. EVIDENCE: A new statement of purpose and service user guide have been produced to reflect the changes in the home. This takes the form of separate documents for the new dementia care unit, which give detailed information to prospective service users and their families, and reflects the philosophy of care being introduced, focusing on person-centred care. New assessment procedures and documentation are being introduced that concentrate on the particular needs of people with dementia, and use material that has been developed by specialists, such as the Alzheimer’s Society and Bradford University, and independent trainers. Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 Page 9 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): These standards will be examined in more detail in future inspections. EVIDENCE: New care planning and care procedures are being introduced, and the impact of these on service users and their families will be assessed in future inspections. Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 Page 10 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): These standards will be examined in more detail in future inspections. EVIDENCE: The effect of new care practices within the home and the new dementia care unit will be assessed during future inspections. Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 Page 11 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’s performance on dealing positively with, and preventing, complaints, is improving and has reached acceptable levels. EVIDENCE: The number of complaints about the home received by the commission (and by local Social Care Services) has dropped to a low level, with none at all in the last 3 months. The home records that there have been 6 substantiated complaints recorded over the last 12 months, 5 of which were described as minor. New staff, including those employed to staff the new dementia care unit, are properly trained, including abuse awareness. Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 Page 12 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 - 26 The new unit has been finished to a very high standard and provides comfortable accommodation. The main home is being well maintained. EVIDENCE: The new unit attached to the rear of the home, to be known as Kingswood, has been completed. The inspection confirmed that all the facilities are now functional and the unit is ready for occupation. The unit will accommodate 16 persons with dementia, on 3 floors. All bedrooms are spacious and well equipped, and have en suite wc’s. They are comfortable and have been furnished and decorated to a high standard. Underfloor heating has been fitted throughout the unit, with bedrooms having individual thermostatic controls. All baths are assisted, and there is a central shaft platform lift. There is adequate communal space. The unit has its own front door and parking area, and a new enclosed garden area to the rear. The grounds have further potential for development to allow Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 Page 13 service users easy access to outside space within a secure and easily supervised perimeter. All the required approvals have been obtained and following the inspection the commission agreed to the home increasing its registration to permit use of the new unit. A wash hand-basin should be fitted in the sluice room, and it is recommended that the lighting in the en suites be improved. In addition it was suggested that consideration be given to providing facilities to make drinks and snacks, and improving the colour scheme and signage to greater assist people with dementia. A brief tour of the main home found it to be clean, tidy, and in good order. It was noticeably fresher and brighter, indicating that the maintenance schedule is now more effective at dealing with the significant amount of wear and tear that buildings such as Kensington House are subject to. The first floor bathroom with sliding door should be fitted with a suitable privacy lock. The front lounges were busy, with much activity, but also conveying a relaxed and good humoured atmosphere. Staff were noted to be interacting in a positive manner with service users. The service users using the rear lounge appear more dependent and there was noticeably less activity (though staff were involved in a shift handover at the time). A new conservatory has been built along the outside of this lounge, providing a link to the new unit, and access to stairs leading down to the rear garden. A new sitting area is being created around the large stairwell and entrance hall at the south end. This area is to become a library and sitting area, with comfortable seating, separated from the passageway by a glass panelled wall. A new link corridor to the Kingswood unit has been created centrally to the rear of the home, and this is glazed to create a light and comfortable area that in places is wide enough to allow comfortable seating to be provided. Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 Page 14 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 - 30 The home is well staffed and staff are appropriately trained to carry out their duties. EVIDENCE: The new unit will be staffed independently of the main home, and a new team has been created to provide specialised care to the people living there. Most of these staff were present on the day of the inspection and the inspector was able to meet and talk with them. It was clear that the new team are well motivated and are approaching their new role in a suitably positive and considered manner. They confirmed that they have received specific training in caring for people with dementia, in addition to the usual essential training for all care staff. There will normally be a minimum of 3 carers on duty during the day, with 2 waking staff at night. An examination of staff records found one file lacked the necessary photograph and proof of identity, but all others were in good order, with the required checks and references being obtained as appropriate. Induction records for staff were examined and were found to be thorough and well kept, with good check-lists to assist tracking of essential aspects of the induction. Essential training is well recorded, with most training now providing staff with certificates, copies of which are kept on file. Certificates demonstrated a good variety of training is provided, in addition to the usual Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 Page 15 essential training in Moving & Handling, First Aid, Food Hygiene, Health & Safety, Infection Control, and Fire Safety. The home now reports that 58 of care staff have completed the NVQ2 award, which achieves the target set within the standards. During the inspection it was noted that staff were interacting with service users in a positive and pro-active manner, and that service users were responding to this in a relaxed and good-humoured fashion. It was also noted during the inspection that the call bell was being answered promptly, and not ringing for long periods as has been the case in the past. Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 Page 16 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, 32, 33, 36, 37, 38 The owners have improved and strengthened the management structure, and developed a more responsive and informed approach to managing the home. EVIDENCE: A new manager, Mrs Stannard, has been appointed, and has applied to the commission to be registered as such. She is an experienced and qualified nurse, currently working towards the NVQ4 Registered Care Managers Award. In addition, a new unit manager (who has already obtained the award) has been appointed specifically to manage the new dementia care unit, under Mrs Stannard’s supervision. The company has appointed various specialist consultants to build and commission the new unit, and to advise on the running and management of the home. It was a feature of the inspection that matters brought up during Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 Page 17 the inspection were responded to immediately and written confirmation of action to be taken was provided before the end of the day. During the inspection, a copy of the latest quality assurance survey of relatives was provided. This is a well presented report, covering essential aspects of the home’s operation, and includes written summaries, quotes from participants, and areas for improvement, as well as detailed statistical information. In addition, the company has revised and improved the format of the monthly internal inspections carried out under regulation 26 of the Care Homes Regulations 2001, and reports under the new approach are being supplied to the commission. Reports from other agencies were also available, and those provided – from Environmental Health, Social Care Services, and the local Fire Service, were all positive. The necessary certificates for building work and the installation and servicing of equipment were also provided and were satisfactory. Other records and documentation inspected were found to be in good order. Supervision of staff takes a variety of forms, many informal, but there are also structured individual sessions for all staff. The management aim to provide at least 6 individual sessions for each member of staff each year, and these are formally recorded. Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 Page 18 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 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 2 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 3 Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 Page 19 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 2 3 Standard OP10OP21 OP29 OP26 Regulation 12, 16 17(2) 16 Requirement A suitable privacy lock must be fitted to the first floor WC sliding door. All staff files must contain proof of identity, including a recent photograph. Sluicing facilities must contain hand-washing facilities for staff. Timescale for action 20/10/05 20/10/05 20/11/05 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 OP19 OP25 OP15 Good Practice Recommendations Consideration could be given to further developing service user access to, and enjoyment of, the grounds. Further consideration could be given to improving the environment such as improved lighting in en suites. Consideration could be given to providing facilities in Kingswood for making snacks and hot drinks. Kensington House Nursing and Residential Home DS0000040035.V254112.R01.S.doc Version 5.0 Page 20 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.V254112.R01.S.doc Version 5.0 Page 21 - 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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