Inspection on 29/04/05 for Kirkley Manor

This inspection was carried out on 29th April 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kirkley Manor 23/07/08

Kirkley Manor 24/07/07

Kirkley Manor 18/05/06

Kirkley Manor 20/10/05

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 & Residential Home 3 Kirkley Park Road Lowestoft Suffolk NR33 0LQ Lead Inspector Mike Usher Unannounced 29 April 2005 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 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 & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kensington House Address 3 Kirkley Park Road Lowestoft Suffolk NR33 0LQ 01502 573054 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Kingsley Care Homes Ltd Miss Deborah McGovern Care Home 54 Category(ies) of OP Old Age (54) registration, with number PD Physical Disability (5) of places Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21/10/04 Brief Description of the Service: The home is registered for 54 service users in 34 single rooms and 10 shared rooms. Of these, 28 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. 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 & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken in response to complaints raised with, or brought to the attention of, the Commission recently regarding the care provided by the home. As such, it looked at a relatively small number of number of standards and did not focus on the views of service users. Some of the matters reported arose from concerns expressed by Suffolk Social Care Services, and refer to actions taken by the home’s management in response. One specific complaint made to the Commission regarding a staffing issue was addressed during the inspection. More inspections will be carried out at a later date to look at other areas of life in the home. The previous inspection report, dated 21st October 2004, will provide more detailed information about the home and should be read in conjunction with this report. The inspection involved the examination of records and other documentation, discussion with the home’s manager, Miss McGovern, and the company’s Operations Manager, Mrs Masters. A brief tour of the accommodation was undertaken, and brief discussions held with staff and service users. In addition, many of the issues referred to are detailed in correspondence between the owners and Suffolk Social Care Services, and are being addressed separately. Consequently, it is not felt necessary to repeat those details within this report. What the service does well: What has improved since the last inspection? Since the last inspection the home has been registered to care for 5 adults between the age of 50 and 65. This development allows the home to provide a more flexible range of care to persons whose needs are similar. Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 6 The home has arranged for staff recruited from abroad to improve their English language skills. An action plan has been produced which addresses the concerns raised by Suffolk Social Care Services. 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 & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 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 standard(s) This area was not looked at in detail at this inspection. EVIDENCE: Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 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 standard(s) 7 The new care plan system is easy for staff to use and contains all the essential information they need to provide care. This should assist staff in providing a good standard of care. EVIDENCE: A new computerised care planning system is being introduced. This is supported by written care records and provides a good deal of information in a format that is quick to access. The information is stored in the ground floor Nurse Station in the open stairwell at one end of the home. A sample of service user’s records were looked at and the information contained was appropriate. New menus have been introduced include provision for diabetics and other specialised diets. Following concerns raised by Suffolk Social Care Services, the home is reviewing the provision of activities, the keyworker system, medication arrangements, and issues around communication. Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 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 standard(s) 12, 14, 15 Improvements being introduced will considerably enhance the standard of care provided and better meet service users’ needs. EVIDENCE: A new seasonal menu has been introduced that aims to provide a varied and nutritious diet for all service users, including those needing special diets, such as diabetics. Special dietary requirements are included in service user’s care plans. A number of issues around care practice and support for service users have been raised by Suffolk Social Care Services following detailed reviews of service users at the home. These reviews found shortfalls in the service provided relating to: Daily activities and supervision Soiled bed linen Inadequate water temperatures Service users personal belongings Communication issues with non-English staff Maintenance of wheelchairs Security of the building I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 11 Kensington House Nursing & Residential Home - Insufficient seating for visitors Isolation of service users in bedrooms An action plan has been produced by the management in response. This provides detailed improvements to many aspects of care practice within the home and is a very positive and active indication of the owners desire to provide a good standard of service. It was noted that on the day of the inspection, a number of the issues identified had already been addressed: • • • • • • Staff given training in bed-making All staff whose first language is not English have attended local college classes to improve their English Building made more secure Wheelchair maintenance actioned Bedroom door restraints fitted Water temperature regulating valves fitted Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16, 18 It is clear that a number of relatives have not felt that their complaints have been listened to or acted upon. Concerns raised by the local authority and the Commission have been addressed and positive action is being taken to correct deficiencies and put in place longer-term improvements to care practice, accommodation, and management. EVIDENCE: The substance of concerns and complaints raised recently is dealt with in some detail throughout this report. Whilst the complaints process has not appeared to work effectively in all cases, there is no evidence that any service users were at risk of harm or abuse. Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19, 25, A number of improvements have been made over the past few months, but too many of these are as a result of criticism by visiting professionals. Many of the issues would not arise with an effective and pro-active management. EVIDENCE: Miss McGovern confirmed that the fitting of thermostatic valves to all hot water outlets was to commence on the day of the inspection. This action is designed to limit the temperature of hot water discharged from these outlets to around 43oC to prevent the risk of scalding. Specialist door restrainers have been fitted to a number of bedroom doors to enable them to be kept open, in line with service users’ wishes, whilst conforming to fire safety requirements. A brief tour of the home was undertaken with Miss McGovern and Mrs Masters. The new extension being built to the rear of the home is nearing completion. When finished, this will be a purpose built unit for people with dementia. Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 14 To improve security, the main entrance is now the only one used by visitors, although users of wheelchair need to enter via a second, ramped, entrance to the front of the building. During the tour, a number of minor items of repair and improvement were noted, such as broken tiles in one of the ground floor bathrooms, and an unguarded radiator immediately adjacent to the small stair lift on the ground floor. Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 The complaint was upheld and it was clear that the recruitment and training procedures had not been followed. An inexperienced carer was included on a night shift without undergoing a proper induction. Whilst there were other experienced staff on duty, the home lacked a full complement of competent, trained staff. The provision of lifting equipment needs to be reviewed to ensure it is adequate, in light of staff comments. EVIDENCE: The records relating to the staff member identified in the complaint were examined. Miss McGovern confirmed that the individual in question had been employed primarily as a Therapist but was sometimes used as a carer. An application form had been completed but the title of the post applied for had been left blank. The form had been signed and dated, but after the events covered by the complaint. Appropriate checks had been carried out but the training record for the carer could not be located. Records showed that the staff member was included as part of the night shift two days after starting work, to cover short-term sickness. From the reported reaction of the individual to the (false) fire alarm that sounded that night, it was clear that they had received insufficient training in essential procedures. At the previous inspection, a short questionnaire was given out to 10 staff. Three of these were returned. Two of these expressed general satisfaction Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 16 with the way that the home operates, though one of these said that an extra hoist would be helpful to cope with breakdowns. The same carer said that the home had improved a great deal in the last 6 months, particularly with regard to team work and language problems. The third carer was less satisfied, feeling that there were not enough staff, they did not receive regular supervision or adequate training (especially with regard to abuse awareness), and they too felt that the lifting equipment provided was inadequate. Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 37, 38. The company has responded very positively and energetically to concerns raised by the Commission, Suffolk Social Care Services and Environmental Health Services. However, the home’s quality assurance process needs to be supported by a pro-active management that engages with relatives directly. In addition, issues raised by third parties are not being detected as part of the company’s own quality control cycle (including audits carried out by the company under Regulation 26 of the Care Homes Regulations 2001). EVIDENCE: Miss McGovern reported that, as part of the home’s quality assurance system, a full survey of all service users and their relatives had been sent out approximately 2 weeks before this inspection. The results of this survey are to be collated and analysed, and any requirements identified will be actioned. Past inspections have confirmed that this has happened. Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 18 A number of concerns have been raised with the Commission over the past 12 months, and a consistent ingredient of those were relatives who had raised concerns with the staff of the home but felt that they had not been listened to. The owners have provided the Commission with a detailed action plan to address the issues raised by Suffolk Social Care Services. This is a very positive document and refers to the advice and support provided by SSCS, which has clearly been of great benefit to the home and will help to improve the service offered. Training records for the member of staff who was the subject of the complaint, were not available. Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 1 15 3 COMPLAINTS AND PROTECTION 1 x x x x x x 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 3 1 x 2 x x x 2 1 Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 20 Yes Are there any outstanding requirements from the last inspection? 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 12, 14 Regulation 12, 16 Requirement Shortfalls identified by Suffolk SCS need to be addressed, as dientified in the action plan produced in response by the registered person. Steps must be taken to ensure that the delivery from hot water outlets is a within reasonable range of comfort, and does not exceed 43o C. Staff must be adequately trained and competent before taking responsibility for their place on the shift. Records required must be available for inspection at all times. The management of the home must be capable and pro-active to ensure that standards are maintained, and avoidable problems do not arise. Timescale for action without delay 2. 19, 38 13 without delay 3. 27, 28, 29, 30 37 16, 31, 33 18, 12 Immediate 4. 5. 17 9, 10, 12, 24, 26 Immediate Immediate RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 21 Kensington House Nursing & Residential Home 1. Standard 30 The home should review the provision of lifting equipment to ensure that it is adequate. Kensington House Nursing & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 5th Floor 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 & Residential Home I54 - I04 S40035 Kensington House V225247 050627 Stage 4.doc Version 1.30 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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