Inspection on 01/12/05 for Kestrel House Lodge Care Home

This inspection was carried out on 1st December 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

Kestrel House Lodge Care Home 20/04/07

Kestrel House Lodge Care Home 09/05/06

Kestrel House Lodge Care Home 22/08/05

Kestrel House Lodge Care Home 21/03/05

Kestrel House Lodge Care Home 01/03/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Kestrel House Lodge Care Home St Thomas` Avenue Kirkby In Ashfield Nottingham NG17 7DX Lead Inspector Susan Lewis Unannounced Inspection 1st December 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 Kestrel House Lodge Care Home DS0000008705.V268844.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. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kestrel House Lodge Care Home Address St Thomas` Avenue Kirkby In Ashfield Nottingham NG17 7DX 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) 01623 757 204 01623 750 512 Keslaw ltd Mrs Josephine Ann Greveson Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2005 Brief Description of the Service: Kestrel House Lodge is a purpose built home accommodating up to 33 older people and provides residential care only. Most of the bedrooms are single, although two doubles are available. There is a passenger lift to the first floor where most of the rooms are situated, as well as a stair-case for those who are able and prefer to use this. There are pleasant gardens to the rear of the accommodation which are enclosed, and the home has approximately 8 - 10 car parking spaces to the front of the property. There is also the availability of on-road parking. The home is close to Kirkby town centre and is located on a quiet residential avenue. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second inspection to be carried out in the annual inspection process; it was undertaken by one inspector and took place over five and half hours. A partial tour of the building took place, communal areas and a random selection of bedrooms were inspected. Visitors, residents and staff were spoken with and staff and care records were inspected. What the service does well: What has improved since the last inspection? The trees obstructing the light in a resident’s window have now been cut, some maintenance work on the windows was seen and staff files have Criminal Records Bureau police checks and references in place. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kestrel House Lodge Care Home DS0000008705.V268844.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 Kestrel House Lodge Care Home DS0000008705.V268844.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): 2, 3, 4 and 5 The admissions process does not ensure that residents admitted to the service will have their needs met, this has the potential to place residents at risk. EVIDENCE: Intermediate care is not provided in this service. Evidence was seen that all residents have contracts, which describe the terms and conditions of living in the home. These are signed where possible by the resident as well as the representative form the home and in the case of a local authority placement, a representative from the local authority. Four care plans were viewed for the purpose of this inspection, these included residents who had recently been admitted to the home and residents whose dependency needs were high. It was clear that residents had been admitted outside the homes category of old age (not falling into any other category and their care plans did not reflect all their care needs, staff did not have the training or experience to meet their needs. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 Page 9 There is a preadmission assessment that is comprehensive but in some cases it was not always filled out in any detail and as some plans did not evidence up to date community care assessments it was difficult to see how comprehensive and detailed care plans could be created. Residents spoken with could either not remember if they had looked at the home prior to moving in or had not had the opportunity to do so. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 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 and 11 Care plans do not always provide information regarding the health care needs of residents with complex needs and how they are met. These shortfalls have a potential to place residents at risk. EVIDENCE: The care plans viewed evidence how residents’ health care needs were to be met, however not all identified needs had a care plan. It was clear from reading a resident’s old assessment that they had care needs around their diet and in discussion with the cook it was evident that there were still issues. However there was no care plan and staff were unaware that this had been an issue is the past. There was evidence that some residents had been involved in reviews but in discussion with residents they were unaware of care plans nor that they could see them. There was evidence that residents had their weight monitored and where residents’ weight changed significantly within a designated period of time this was actively followed up and advice was sought from the GP or dietician. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 Page 11 Residents spoken with said that they were able to see a GP when they wanted and visitors confirmed that they were informed if their relative had needed medical attention. Risk assessments had taken place regarding risk of falls and pressure care with supporting care plans to minimise risk. Medication was not fully inspected however its administration was observed and staff were spoken with regarding procedures. It was noted that not all residents are observed taking their medication before it is signed to say it has been taken. Where this has been agreed with the resident, this practice must be risk assessed and appear in the resident’s care plan. Staff spoken with confirmed that they received training to administer medication and that only trained staff were allowed to administer. Staff spoken with understood the importance of signing twice for controlled medication. The medication administration records were viewed and where medication has been hand written the registered person must ensure that it is signed and witnessed as being correctly entered. Care plans included some limited information regarding residents’ wishes should they deteriorate and die. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 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): 14 and 15 Meals are nutritious and balanced and offer a healthy and varied diet for residents. Residents do not feel they are able to exercise control over their lives. EVIDENCE: Residents spoken with said that they did not feel involved in making choices in the home, they confirmed that they were able to get up and go to bed when they wanted to, this was recorded in their care plans. Residents spoken with said that their relatives handled their finances and when they moved into the home they were able to bring some personal possessions, inventories were noted in care plans. Residents spoken with were unaware of their care plans nor that they had a right to look at them. The registered person must ensure that all residents have access to their personal records in accordance with The Data Protection Act 1998. Residents spoken with generally felt the meals were good although some commented that that quality was not as good as it used to be. Evidence was seen that a choice is provided as well as alternatives for those that do not want the meals offered that day, however residents said that they were not involved in menu planning. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 Page 13 Homemade cakes were available for the teatime meal. It was appropriately recorded providing information to show a nutritious diet was offered to residents. Staff were seen going to all residents and asking them what they wanted to eat, this was noted for lunch and tea. The dining room provided a reasonable setting but one wall had ripped wallpaper and flaking plaster as well as the vacuum cleaner and weighing scales stored in one corner. This will be discussed further under standard 19. Staff were seen to provide discreet assistance as required and residents were able to eat their meal in their own time. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 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): 17 and 18 Resident’s civic rights are supported and staff have the skills and knowledge to protect residents from abuse. EVIDENCE: Residents spoken with said that they had been able to vote at the last election either via postal ballot or by visiting the polling station. Staff spoken with had a clear understanding of what constituted abuse and what they needed to do should they either witness it or suspect it. Residents spoken with said that they felt safe in the home and that carers were kind and caring. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 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, 23, 24, 25 and 26 Some improvements to the décor have been made. There are a number of serious matters outstanding, which put people at risk of serious harm and do not provide safe and comfortable surroundings in which to live. EVIDENCE: An immediate requirement was left at the last inspection regarding the trees blocking the light out of a resident’s bedroom window; evidence was seen that this work has been completed. During the inspection the Estates Manager was seen with a builder looking at outstanding work to be carried out, at the last inspection an immediate requirement was left to ensure that the fire doors that had been vandalised during an attempted break in were repaired. This work has yet to be completed. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 Page 16 Another fire door leading from the laundry had a notice on stating ‘Do not open as you may not be able to close it again.’ The door was clearly in a state of disrepair and a large gap had appeared at a join. This is not acceptable and places staff and residents at risk. An immediate requirement was left and the work must be completed by 09/12/05. As previously mentioned the dining room had a large area of wallpaper peeled off and the plaster was bubbling and flaking. This is both unsightly and shows there is a lack of maintenance to the building. Residents spoken with said that they felt that the building was getting shabby and this had been happening for some time and they felt there was an air of neglect. There was some evidence of renewal of furniture and carpet in the living room area. The maintenance man was seen renewing the putty to the windows, this was a requirement set at the last inspection and the timescale for action of 1st December 2005 was met. There is currently one large lounge and dining area, there is no private space for residents to meet with visitors in private other than their bedrooms. Bedrooms viewed were clean and tidy providing residents with a comfortable and homely environment. Residents spoken with said they liked their bedrooms and where residents shared appropriate screening was available. Bedrooms provided a lockable space for those who wanted it suitable lighting and heating that residents could regulate themselves. Radiators were all guarded minimising the risk of burns. In the bedrooms viewed, only two single sockets were available and sometimes these were at the side of the bed and therefore not always accessible to residents. The home was clean and tidy however the laundry area had an ‘off cut’ of carpet on the floor, this was not only a trip hazard but it meant the floor was not readily cleanable to minimise the risk of infection and toxic conditions. The registered person must ensure that a risk assessment is carried out as to the safety of this carpet. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 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, 29 and 30 The procedures for the recruitment of staff are and protect the people living in the home. Staff have access to training to ensure they are competent to do their job. EVIDENCE: Residents spoken with all said that staff were lovely and caring and ‘would do anything they could to help’. However all residents said that they felt that staff were stretched and often exhausted. Visitors spoken with said that as some residents could be demanding this put a great deal of stress on staff also that there had been a lot of new staff start. Staff spoken with said that usually there were four staff on the morning shift then three on the afternoon staff also confirmed that there had been a high level of staff turn over. Although on the day of the inspection this appeared enough staff as number of residents had gone out for an activity, if all the residents were at home this could place a great deal of strain on the staff. It is recommended that the registered person look at the dependency levels of residents along with staffing to ensure that there are enough staff at all times. A requirement was set at the last inspection regarding Criminal Records Bureau checks. The staff files viewed all had appropriate police checks and references. This requirement is met. Staff spoken with said that they were encouraged to undertake training and were given time to attend. On the day of the inspection a new member of staff was seen with another member of staff going through her induction ensuring she knew where things were in the home. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 and 38 Staff and residents are not been given a clear sense of direction by the acting manager. Staff are not being supervised to ensure consistency of practice. EVIDENCE: A requirement was set at the last inspection for the acting manager to submit an application to the Commission to be considered for registration as manager of the home by 23 September 2005. An application has yet to be received by the Commission. The registered person must ensure that there is a registered manager for this home. Residents and staff spoken with did not feel that the acting manager gave a clear direction of the standard of care expected and as there were no staff meetings or residents’ meetings they were unable to affect the way the service was delivered. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 Page 19 Action plans are received by the Commission to show how requirements are to be met, however timescales are not always met. Staff spoken with said that they did not receive formal supervision from their line manager but spoke to the deputy manager if they needed guidance. Staff spoken with said that they had received their mandatory training and evidence was seen that training was being renewed. There was evidence that the fire extinguishers had been maintained and the requirements set by the recent Environmental Health Officer report had also been met. However the cleaning schedule for the kitchen was confusing and was not always filled in. All accidents and injuries are recorded and reported as necessary to the Commission. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 1 1 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 1 X X X 3 2 3 2 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 2 X X 2 X 3 Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement Timescale for action 01/01/06 2 OP4 12, 18 The Registered Person shall not provide accommodation to a service user at the care home unless, so far as it shall be practicable to do so the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. The two identified service users whose needs fall outside the registration of the home must be found suitable alternative accommodation. The Registered Person shall 01/01/06 having regard for the size of the care home, the statement of purpose and the number and needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home. The Registered Person must not admit people outside of category. (An Immediate Requirement was left in regard this standard) DS0000008705.V268844.R01.S.doc Version 5.0 Kestrel House Lodge Care Home Page 22 3 OP7 15 4 OP8 13 5 OP9 13 6 OP19 13, 23 7 OP26 13 The Registered Person shall after consultation with the service users, or representative of his, prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met. Care plans must be written in sufficient detail to reflect the service user’s needs and the service user identified with eating habit issues must have a care plan that reflects that need. The Registered Person shall make arrangements for service users to receive where necessary treatment, advice and other services from health care professionals. Advise must be sought and documented concerning the resident with eating issues. The Registered Person must ensure that medicine record sheets are appropriately signed and witnessed when hand written. The Registered Person shall ensure that all parts of the building to which service users have access are so far as possible free from hazards to their safety and the premises to be used as the care home are of sound construction and kept in good state of repair externally and internally. The identified fire doors must be repaired. (An Immediate Requirement was left in regard this standard) The Registered Person must ensure that the laundry area is free from trip hazards and that the floor is readily cleanable. The ‘off cut’ off carpet should be risk assessed as to its suitability in the laundry environment. DS0000008705.V268844.R01.S.doc 31/01/06 01/02/06 01/01/06 09/12/05 01/02/06 Kestrel House Lodge Care Home Version 5.0 Page 23 8 OP31 18 9 OP32 10 OP36 The Acting Manager is required 01/01/06 to submit an application for consideration of Registered Manager. (Outstanding Requirement from 23/09/05) 10, 12, 21 The Registered Person shall 01/02/06 ensure that the acting manager has the skills and competencies to carry on as manager of the home and ensure that service users, staff and other stakeholders are able to affect the way in which the service is delivered. 18 The Registered Person must 01/03/06 ensure that staff are appropriately supervised. 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 4 5 Refer to Standard OP14 OP15 OP24 OP27 OP33 Good Practice Recommendations The Registered Person introduce residents meetings to enable residents to be involved in decision making in areas such as menu planning. The Registered Person should find alternative storage for the vacuum cleaner and weighing scales. The Registered Person should ensure that electric sockets are accessible to service users. The Registered Person should ensure that staffing levels are sufficient to meet the needs of residents at all times. The Registered Person should carry out quality surveys amongst service users and other stakeholders. Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Kestrel House Lodge Care Home DS0000008705.V268844.R01.S.doc Version 5.0 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!