Inspection on 22/06/06 for Kilburn Care Centre

This inspection was carried out on 22nd June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kilburn Care Centre 17/04/07

Kilburn Care Centre 05/10/05

Kilburn Care Centre 09/12/04

Kilburn Care Centre 12/07/04

Kilburn Care Centre 22/03/04

Kilburn Care Centre 23/02/04

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 Kilburn Care Centre Dale Park Avenue Kilburn Belper Derbyshire DE56 0NR Lead Inspector Ivan Barker Unannounced Inspection 22nd June 2006 09:00 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 Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kilburn Care Centre Address Dale Park Avenue Kilburn Belper Derbyshire DE56 0NR 01332 880644 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) kilburnnursing@highfield-care.com Southern Cross Care Homes No 2 Limited Mr Chris Cooper Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (49) of places Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. To admit one (named) service user under the age of 65 years in the category of PD. One DE(E) place for the service user named in the notice of proposal letter dated 24/11/04. One DE(E) place for the service user (EM) as named in the notice of proposal letter dated 05/05/05. The registered person will be responsible for informing the Commission for Social Care Inspection when the named individuals no longer reside at the home. 5th October 2005 Date of last inspection Brief Description of the Service: The home was two homes, which have been joined to create one registered home. One was a converted building, the other a purpose build. The home is built on four levels, however the home is a two-storey building. Currently the converted building has service users, who require personal care and the purpose built section has service users who require nursing care. The registration is for 49 service users receiving personal or personal care with nursing. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on the ‘key standards’), and the previous requirements. The person present at the inspection was: Mr C Cooper, manager. Within this inspection, which occurred over a four-hour period, the inspector toured the building, examined requirements relating to the previous inspection, spoke with service users, and staff and examined some documentation. What the service does well: What has improved since the last inspection? What they could do better: The requirement regarding the health and safety of visitors staff and service users should have been resolved within the timescales stated within the last report. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 6 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. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Accurate assessments will ensure that the home has sufficient information to be aware of the service user’s needs prior to admission. EVIDENCE: The home received service user’s assessments from the Social Services Care managers or the hospital prior to admission. The manager prior to admission to the home assessed all service users. The inspector was shown evidence of the assessments of the service users, who he case-tracked. Within some of the service user’s assessments it was identified that ‘confusion’ was a need to be met. On discussing these needs with the manager, the inspector was advised that the service users physical problems were their primary needs and their confusion was a secondary need. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 9 Regarding Standard 6, the manager advised the inspector that the home did not provide intermediate care. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Accurate care plans will contribute to the delivery of care. Service users were satisfied with the care they received. The weakness in the fire integrity of the medication room door may place the staff, visitors and service users at some risk. EVIDENCE: On examination of the care plans, from the service users who were being case tracked, the inspector established that all 3 plans were up to date, and had been evaluated on a monthly basis. The inspector discussed the service users’ care needs with care staff, who were knowledgeable about the service users’ needs. Risk assessment were included within the documentation and included moving and handling, pressure area, and nutritional risk assessments. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 11 The inspector spoke with the service users who were being case tracked. They informed the inspector that in their opinion, ‘The care was good’. ‘The care was excellent’. On auditing the storage of medications, the inspector found that a hole had been cut through the top section of the door to the medication room. A plastic ventilation grill had been fitted to the outside of the door, with the inner aspect of the door displaying a rectangular hole. The manager advised the inspector that he had followed the company guidance, that all medications rooms must be ventilated. However by taking such action, the fire integrity of the door had been compromised. A specific type of ventilation grill, which seals from the heat of a fire, could have been fitted. This factor was particularly important, as oxygen cylinders were stored within this room. On examination of the medication administration the inspector observed that the medication administration records were up to date with all the records signed as appropriate. Visitors were allowed to visit the service user in the communal areas or in the privacy of their own room. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Various activities were organised within the home, which would provide stimulation to service users and enhance their quality of life. Service users were given the opportunity to exercise their right of choice regarding the provision of meals. EVIDENCE: The manager informed the inspector that 3 staff were employed as activities co-ordinators and worked a total of 35 hours per week, (16hrs, 8 hrs and 7hrs respectively). Therefore, this flexibility in the activities co-ordinators hours allowed for activities to occur, for example, if 2 activities co-ordinators were needed for an outing, this could be achieved because of flexibility of their employment. The activities programme was displayed, and available within the activities coordinator’s records. The manager produced the activity co-ordinators records which indicated what activities had occurred and who participated in the activity. The entries also indicated if service users had been offered the opportunity to participate and if they had refused the option. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 13 Also one to one sessions were recorded. The manager advised the inspector that the home had created a ‘boules’ league, which was a firm favourite with some of the service users. The manager showed the inspector, the service users’ surveys for the last quarter of the year, which indicated that the service users were satisfied with the activities. On discussing the activities with the service users, the inspector was informed that ‘they had a chance to play bingo’ and ‘had entertainers’. Also that ‘people sat and chatted to them’, and ‘the television was available when we want it’. The inspector established that the service users were generally happy with the activities. The comments received by the inspector did not fully support the evidence provided by the records, planners and other evidence of activities, within the home. The inspector was of the opinion that various activities, including one to ones sessions did occur, but this was not reflected by the service users comments. Regarding the meals, the manager informed the inspector that there was a choice of meal. The manager advised the inspector that the service users were able to order their meals in advance, but the service users often changed their minds at lunch or teatime. This had created problems, however the catering staff had provided sufficient meals to allow this ‘second choice’ at the mealtime to occur. Again the manager provided evidence of a service user survey, which had been undertake regarding their views on the meals. One comment, which was shown to the inspector, was that some service users requested ‘smaller portions’. The inspector received positive comments from the service users. The general comments were that ‘a choice of food was available’, and ‘there was plenty of food’. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There was evidence that complaints were taken seriously and acted upon. This action may give assurance to complainants that their complaints were taken seriously and play some part in enhancing the quality of care and service provision. The staff had received Adult Protection training. Therefore staff would be aware of their responsibility regarding the protection of vulnerable adults and this may provide protection for service users. EVIDENCE: The complaints procedure was displayed and available to the service users and relatives. Four complaints were recorded in the complaints file. The complaints had been received in various formats i.e. verbal and written. Two of these complaints were anonymous. The manager had been proactive regarding the recording and investigating of the complaints, some of which may be preserved as minor. A discussion occurred between the manager and inspector regarding the importance of recording complaints. The discussion revolved around the point that some managers within other care settings may receive complaints but do not record them, as it can be persevered as a negative. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 15 The benefits of recording complaints will provide evidence and assurances that complaints are actively acted upon, and form part of a quality assurance could be used to enhance the quality of care and service provision. All recorded complaints were investigated according to the company policy and complaints were resolved within the expected timescales. On discussing complaints with the service users, they informed the inspector that they had no complaints. No complaints were addressed to the inspector, at the time of this visit. One concern was addressed to the inspector prior to the inspection. The individual requested that the information provided be monitored as part of the inspection process rather than as a complaint. The inspector raised the concerns and examined the issues raised as part of the inspection, and these have been addressed in other sections of this report. The home had policies and procedures relating to the Protection of Vulnerable Adults. The staff undertook Adult Protection training using a CD ram, which had been provided by Derbyshire County Council. On requesting to see the training records relating to Adult Protection Training, The manager provided the training record, but it was yet to be completed. However he assured the inspector that all staff had received the training. To test this statement, the inspector questioned the staff, who were on duty. They confirmed with the inspector that they had undertaken training from the CD ram and had received a copy of a summary card, which was provided as part of the training. A member of staff showed a card to the inspector. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 16 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): Standards 19, 20, 22 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The environment, monitored at this inspection, had not been maintained to the required standard to provide a safe, environment for services users. EVIDENCE: On touring the home the inspector found that the interior of the home was well maintained, well furbished and well decorated throughout and odour free. The previous requirement relating to the lighting fittings had been addressed. However the requirement relating to the drive, patio and rear steps had not been resolved. The manager provided evidence that he had pursued the matter with the estates department of the company, however the repairs had not been undertaken. The inspector raised his concerns that the requirement was still outstanding and that the issue remained a health and safety concern to visitors, staff and service users. At the inspection, the inspector identified that as the manager was unable to provide a completion date, then he would Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 17 need to discuss his concerns and requirements with the Health and Safety Executive. Following the inspection, the manager contacted the inspector and advised him, that the areas had been ‘made safe’, and that the repairs would be undertaken and completed within the next two weeks. The inspector accepted the offer of this timescale and it has been recorded in the requirement section of this report. During the inspection the inspector examined the wheelchairs, which were being used on a ‘communal’ basis. The manager advised the inspector that he was aware that some wheelchairs had been used without the use of footrest. Since he became aware of the issue, the wheelchairs had been fitted with ‘split pins’ to ensure that they remained on the chair. Also 6 new wheelchairs were on order. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The staff recruitment process should provide protection for the service users. The manager was able to provide evidence that staff had received training, which should reflect on the quality of care being delivered to the service users. EVIDENCE: On examination of the rota the following was indicated. Am shift. 2 qualified nurse plus min 7 to max 9 care staff. Pm shift. 1 qualified nurse plus min 6 to max 8 care staff. Night shift. 1 qualified nurse plus 4 care staff. Plus, the manager and activities co-ordinator. Caring for 46 service users on two units. A full assessment of the dependency levels of the service users was not undertaken by the inspector and compared with the indicated staffing levels. On examination of the 3 staff files, all 3 contained the required documentation, including Criminal Records Bureau checks. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 19 In relation to Moving and Handling, Fire training, the manager showed the inspector the training records that indicated these and other specific clinical training had occurred. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 20 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): Standards 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The management of the home does comply with the requirements of the Care Homes Act. Extensive quality assurance systems were in place that should assist the manager and operation manager to measure the home against expected outcomes. EVIDENCE: Within the management structure of the company there was a registered manager who was supported by a regional operations manager. The registered manager had obtained The Certificate in Health and Social Care from Leeds University. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 21 The company had quality assurance systems, which were implemented by the manager and validated by the operations manager. The quality assurance monitoring system was extensive and monitored areas such as care plans, risk assessments, complaints, and service provision. On examination of the staff supervision records, the inspector established that staff had received supervision. The standard required supervision to occur six times a year. The home was on course to achieve this number of supervisions. Regulation 26 visit occurred and reports produced. These were shown to the inspector. Regarding the service users’ personal monies the home operated a basic credit and debit system, but involved the storage of monies in separate envelopes. On examination of the system, examining the accounts of the service users who were being case-tracked, the inspector observed that the money in the envelopes was correct to the accounting record. Regarding Standard 38, Health and Safety issues have been raised in other sections of the report. Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 23 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 OP20 Regulation 12 and 23 Requirement The registered person must ensure that the rear patio, the drive and steps adjacent to the patio receive such attention to ensure the safety of the service users. ( previous requirement) The registered person must ensure that the medication room door provides the necessary fire protection. Timescale for action 06/07/06 2 OP9 12 22/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Kilburn Care Centre DS0000058025.V300972.R01.S.doc Version 5.2 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. 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