Inspection on 22/08/05 for Kestrel House Lodge Care Home

This inspection was carried out on 22nd August 2005.

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

Kestrel House Lodge Care Home 20/04/07

Kestrel House Lodge Care Home 09/05/06

Kestrel House Lodge Care Home 01/12/05

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 Selwyn Marston Unannounced 22 August 2005 @ 11:55 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. Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 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 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 750512 Acting Manager Julie Hampson Care home only (PC) 33 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st March 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 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to this inspection information was gathered from the previous inspection and registration records. This inspection took place over 5 hours and was carried out by Selwyn Marston the lead inspector as the first of two statutory inspections scheduled for 2005 - 06. The main method of inspection used was “case tracking”. This involved selecting three service users and tracking the care and support they received through the checking of their records, discussion with them, the Acting Manager, care staff and observation of care practices. It also included a general discussion with five other service users. An internal and external tour of the home was undertaken including the viewing of four bedrooms. Records to support care practice and records relating to staff were also inspected on this visit. What the service does well: Relatives interviewed were very complimentary of the care and support offered by the Acting Manager and her staff team. They are always made welcome and that nothing was ever too much to ask for. Care staff treated service users with dignity and respect; it is a happy home to live in. Both relatives and service users stated that they are able to raise concerns with the Acting Manager or members of the staff team if they wished. Staffing levels are adequate to meet the needs of service user. Service users stated that staff, were always available to offer assistance when required. Service users health care needs are well catered for and staff demonstrated a good understanding of service users individual needs. Service users are able to access to a range of activities, they can access the community on trips out. Visitors are welcome throughout the day. The standards of cleanliness throughout the home are maintained to a good level. Service users bedroom provide a comfortable space and are well maintained. Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 Page 6 What has improved since the last inspection? 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 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 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 Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 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) 3 Service users are appropriately assessed to ensure that their identified needs can be met. EVIDENCE: Care Plans evidenced that the social worker and Registered Manager have undertaken an assessment prior to the service user being admitted. The Assessment Admission document within Care Plans contains detailed information of the support required to meet identified needs. The Acting Manager stated her intentions to continue to assess all future admissions in addition to the assessment undertaken by the social worker. Intermediate care (Standard 6) is not applicable to this home. Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 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, 8, 9, 10, 11 The health and social care needs of each service user is known and the provisions to meet them are in place. Service users’ right to privacy and respect is upheld. The choice and the decisions made by service users are respected. EVIDENCE: Three Care Plans were ‘case tracked’ and they all evidenced in detail, the support and input required to meet them. Care staff demonstrated good knowledge of individual needs and how the service user wishes the support to be delivered. The Care Planning system is reviewed each month. Health Care needs is documented within the Care Plan of each service user. Service users stated that they were well looked after and if there are any concerns you can ask to see the GP. Service users who were required medication stated that staff took responsibility for ensuring that were well stocked up and would ask if there were any concerns regarding being well. Service users were happy with the levels of respect that was shown by care staff. Observation of the interaction between service users and staff revealed that close relationships had been forged. Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 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, 13, 15 Service users are able to exercise choice in the social activities as they wish. Arrangements for catering are well managed and reflect service users likes and dislikes. Service users are able to entertain visitors as they wish. EVIDENCE: An activities organiser is employed in the home to provide group and individual input to all service users. Four service users were observed playing cards prior to tea. The main lounge area offers ample space for games and activities. A couple were able to waltz to a ‘music hall’ compact disc that was a favourite of theirs without this being imposed on other service users. Service users interviewed stated that there is wide range of activities on offer including trips out. Records kept by the activities organiser evidenced the individual time and offer of activities provided to each service user. Relatives interviewed stated that they were always made welcome and that the staff are very good. During their visits to the home they stated that they often observed staff spending time with other service users to check that they were okay. Service users explained that the catering staff have a system of checking with each service user prior to each meal what they would like. Alternatives are provided following a discussion with the catering staff. Service user praised the quality and quantity of food provided. Menus evidenced a variety of meals on offer throughout the week. Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 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 standard(s) 16, 18 The welfare of each service user is actively promoted. Service users are able raise complaints within in an environment in which they feel that their concerns are responded to without prejudice or victimisation. EVIDENCE: There have been no documented complaints since the last inspection. The Acting Manager stated that there are no current complaints in progress or pending. Service users and relatives spoke of the complaints procedure displayed on the main notice board. They all stated that they felt at ease to raise concerns with staff on duty or speak to the Acting Manager. They all confirmed that they have not had any reason to raise a complaint. Staff on duty were aware of the adult protection procedures and the need to share all concerns with the Acting Manager or the senior on duty. Information regarding the Nottinghamshire Adult Protection procedures is readily available to staff. Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 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 standard(s) 19, 20, 21, 22, 26 Service users living in this home live in a comfortable environment. The overall standard of the décor and furnishings are good. Attention is required to the building repairs identified to ensure that a safe environment is maintained. Staff and service users have access to equipment to assist and maximise individual independence. EVIDENCE: A tree has severely restricted the views and light into two bedrooms. Quotes for the work to trim the trees have been gained however the Acting Manager does not have a date when this work would begin. Two external doors from the main communal lounge have been vandalised from an attempted break-in. As a result, the security of the building has been compromised and could remain a target. The paint on external wooden window frames is flaking and wood is exposed. Sealed glazed units have missing putty. Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 Page 13 Fire doors on the first floor are alarmed. This is activated when the door is opened however, if the door is immediately closed the alarm stops. The alarm is not connected to an indicator board. Given the layout of the home it is possible for a service user to leave the building without staff knowing, which door has been used, if staff do not happen to be within hearing distance of the alarm. Relatives stated that the home is always kept clean. All areas of the home viewed were clean and tidy. Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 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 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 staffing complement and skills mix are adequate to meet the assessed needs of service users. The recruitment and vetting of staff are well managed to ensure the safety and wellbeing of each service user. EVIDENCE: The home is appropriately staffed to the agreed staffing levels made prior to the Commission for Social Care Inspection. The Acting Manager stated that their were no concerns regarding the current staffing levels as they reflect the needs of service users currently accommodated. The staff rota was maintained up to date and reflected the staff on duty at the time of the inspection. Three staff files were selected and these did not contain all the required checks has stated in Standard 29. Files evidenced the following in relation to Criminal Records Bureau (CRB) checks; one was missing for one individual, one contained the reference number to the check (carried out) and a copy of the check was in place. A separate training folder is in place and this evidenced Fire Safety, Health & Safety, Infection Control and First Aid have recently been undertaken. Training is devised for all grades of staff. Training and development is consistent with home’s Statement of Purpose, care practice and meets national workforce planning targets. Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 Page 15 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) 31,32, 34, 35, 37 The Responsible Individual and Acting Manager offer good levels of support and leadership in this home. The management team are transparent and service users are able to direct the way service is delivered. EVIDENCE: The Acting Manager has been in post since March 2005 and is in the process of forwarding an application to the Commission for Social Care Inspection to be considered as the Registered Manager. Although new to the post the Acting Manager has significant experience in relation to staff training and development. Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 Page 16 The Acting Manager operates an ‘open door’ policy and has spent a good deal of time getting to know service users, their relatives and the staff team as a whole. The Acting Manager states that she is committed to providing care in an open and realistic way. To create an environment, where service users feel that Kestrel Lodge is happy home and staff are appropriately trained to provide a high standard of care. The Acting Manager stated that there has been excellent support from the regional manager since being post. Since the last inspection the management of service user’s finances has been reviewed. A new system to improve on what was a fairly robust system has now been introduced. Records in relation to service user’s monies were maintained up to date. All monies relating to service users are securely stored. Records relating to service users are safely and securely stored. Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 Page 17 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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 x x 4 x 3 x Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 Page 18 NO 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 19 Regulation 23 Requirement Confrimation of the date for the work to commence in cutting of trees identified that block the rooms of service users. Confirmation of date for the work to commence on the lounge fire doors following attempted breakin Attention required to window to decorate and to ensure glazing is secure. Ensure CRB checks are undertaken on all employees. The Acting Manager is required to submit an application for consideration of Registered Manager Timescale for action Immediatel y Immediatel y 1st Dec 05 19th Sep 05 23rd Sept 05 2. 19 23 3. 4. 5. 19 29 31 23 19 18 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. Refer to Standard 3 12 Good Practice Recommendations Keyworkers to evidence that individual service users have been involved in the review process of their Care Plan. Provide a plan of training specifically to meet the needs of the activities person. 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 Page 19 Kestrel House Lodge Care Home 3. 19 Review alarm system on first floor fire doors. Kestrel House Lodge Care Home 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 Page 20 Commission for Social Care Inspection 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 20050822 Kestrel House X10015 UN Stage 4 S8705 V245527 C53.doc Version 1.40 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. 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!