Inspection on 05/10/05 for Kilburn Care Centre

This inspection was carried out on 5th October 2005.

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

The inspector 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 22/06/06

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 0PR Lead Inspector Ivan Barker Unannounced Inspection 5th October 2005 09:30 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.V255684.R02.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. Kilburn Care Centre DS0000058025.V255684.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kilburn Care Centre Address Dale Park Avenue Kilburn Belper Derbyshire DE56 0PR 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.V255684.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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. 11th May 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.V255684.R02.S.doc Version 5.0 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 several of the ‘key standards’), and the previous requirements. The persons present at the inspection were: Mr C Cooper, manager. Mrs S Edens, acting region manager. Within this inspection, which occurred over a five hours and fifty minute period, the inspector toured the building, spoke with service users and staff and examined the care plans and other documentation. Two service users, and staff were spoken with during the inspection. Unfortunately no relatives were visiting at the time of the inspection. However he did speak with one relative over the telephone. During the inspection, Mrs Angela Kennedy, inspector, as part of an induction process, accompanied the inspector. What the service does well: What has improved since the last inspection? There has been the appointment of an activities co-ordinator who was a very enthusiastic individual. This had resulted in a dramatic increase in the provision of stimulation to the service users, which will provide a better quality of life. Kilburn Care Centre DS0000058025.V255684.R02.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. Kilburn Care Centre DS0000058025.V255684.R02.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 Kilburn Care Centre DS0000058025.V255684.R02.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): Standard 3 Accurate assessments will ensure that the home has sufficient information to be aware of the service user’s needs prior to admission. EVIDENCE: The manager or senior staff undertook an assessment of the service user, prior to admission. The home also obtained the assessments, prior to admission from Care managers and Nursing staff from the hospitals. These assessments provided the basis for the completion of the care plans, which contained the assessments detailed in Standard 3. Kilburn Care Centre DS0000058025.V255684.R02.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 7 Inaccurate care plans will not contribute to the delivery of care, and may place the service users at risk. A Relative and service users who spoke with the inspector were satisfied with the delivery of care. EVIDENCE: These standards were not assessed on this inspection except for previous requirements, within Standard 7. At the last inspection, some of the care plans had not been re-evaluated on a monthly basis. On examination of 4 care plans, the inspector found that 3 of the 4 documents were up to date. The document, which was not up to date, had been re-evaluated on the 21/08/05, and should have been re-evaluated again, by the 21/09/05. This inspection occurred on the 5/10/05. On discussing the shortfall with the manager, he examined the document and informed the inspector that it was the same qualified nurse, who had not reevaluated her care plans at the last inspection. The manager agreed to discuss this matter with the individual member of staff. Kilburn Care Centre DS0000058025.V255684.R02.S.doc Version 5.0 Page 10 During the inspection, a relative contacted the manager by telephone, to discuss her mother’s care. On discussing her care, the manager offered the relative the opportunity to talk with the inspector. During these discussions the relative informed the inspector that she was satisfied with the care, and commended the efforts of the staff. During discussions with the service users, they informed the inspector that they were satisfied with the care. Kilburn Care Centre DS0000058025.V255684.R02.S.doc Version 5.0 Page 11 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, 15. Various activities were organised within the home, which would provide stimulation to service users and enhance their quality of life. An alternative choice of meal was available to the service users. Service users were given the opportunity to exercise their right of choice, and were satisfied with the provision of meals, and the activities. EVIDENCE: On examining the standards relating to activities and choice the inspector established the following: Since the last inspection the home had appointed an activities co-ordinator. She was invited into the manager’s office to speak with the inspector. She identified that since her appointment she had created a ‘log book’ of service users interests and a record of their participation. Unfortunately the record was not available for examination by the inspector, at the time of the visit. Through his discussions with the activities co-ordinator, he established that she was a very enthusiastic individual, who was keen to enhance the quality of life of the service users. She informed the inspector that she undertook various activities with the service users, dependent on their needs. Kilburn Care Centre DS0000058025.V255684.R02.S.doc Version 5.0 Page 12 Examples given were one to one sessions with service users with dementia, and outings of six people to the zoo. The inspector was shown photographic evidence of the trip to the zoo. The photographs showed that the service users were enjoying the trip. On discussing the activities with service users, they informed the inspector that they were satisfied with the activities within the home, which included entertainers visiting the home and also the outings. They also informed the inspector that they are able to go to bed and get up whenever they wished and that the food was good. On examining the provision of food, the inspector was shown evidence that there was an ordering system in place and that the service users were asked the previous day of their choice of breakfast and main meal. An alternative meal choice was indicated on the menu document. Kilburn Care Centre DS0000058025.V255684.R02.S.doc Version 5.0 Page 13 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): None. EVIDENCE: These standard were not assessed. The key standards were examined at the last inspection. Kilburn Care Centre DS0000058025.V255684.R02.S.doc Version 5.0 Page 14 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, 20, 25, 26. The environment, monitored at this inspection, had not been maintained to the required standard to provide a safe, well-maintained environment for services users. EVIDENCE: These standards were not fully assessed on this inspection, except for previous requirements, and issues relating to the environment, which were observed at this inspection. The previous requirements were: • • • • The raise / lower bar had been refitted and was secure. Within Room 42 a new carpet had been fitted. On examination of Room 8, the bushes from outside the window had been cut back to allow an improvement of natural light. The lights elements were still exposed, and covers had not been fitted, or the light replaced. The manager informed the inspector that this issue DS0000058025.V255684.R02.S.doc Version 5.0 Page 15 Kilburn Care Centre had been raised directly with the estates manager of Southern Cross healthcare, and would be resolved within the next two months. During his examination of the light levels within Room 8, because of the removal of the bushes, the inspector observed from the window, that a bench had been placed across steps leading from the patio. On discussing this fact with the manager, he advised the inspector that the bench had been placed in front of the steps, as an interim measure, to prevent service users with dementia and poor eyesight from falling down the steps. The inspector went out of the building to examine the steps and found several areas of the block paving and the patio area to contain tripping hazards. On examination of the bench, the inspector accepted that this was only a temporary arrangement, however it did restrict access around the building and may reduce the options of the means of escape in the event of fire. The manager assured the inspector that he would raise these issues identified above, with the estates manager. Kilburn Care Centre DS0000058025.V255684.R02.S.doc Version 5.0 Page 16 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, 30 Current staffing levels in place would appear to meet the current dependency needs of service users, accommodated within the home. However insufficiently trained staff may place service users at risk. EVIDENCE: The manager informed the inspector that since the last inspection, and because of the dependency needs of the service users, there was now two qualified on the am shift, and the addition of an activities co-ordinator. The inspector examined 4 staff files and found that all the files contained the information required in Schedules 2 and 4. Regarding training, NVQ training did occur and the statutory training relating to fire, moving and handling etc did occur. However it was established that one member of staff had not undertaken these courses. The manager informed the inspector that he would address this issue immediately. The manager advised the inspector that the member of staff would attend a basis fire induction course, tomorrow morning (6/10/05), with further training to occur on the 21/10/05. Also moving and handling training was to occur on the 10/10/05. The inspector accepted that this was an oversight and that the manager was to act upon this shortfall. Kilburn Care Centre DS0000058025.V255684.R02.S.doc Version 5.0 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 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. 36 Quality assurance systems will assist the manager’s and company to measure the home against expected outcomes. EVIDENCE: The home had quality assurance systems, which were provided by the company. These systems included regular monitoring by the region manager, auditing of the home in areas such as care plans, environment etc, as well as relative, service user meetings and questionnaires. There were monies held by the home, on behalf of the service users. The home operated a simple credit and debit system. Regulation 26 visits occurred on a monthly basis. Kilburn Care Centre DS0000058025.V255684.R02.S.doc Version 5.0 Page 18 Staff supervision had occurred and was on target to achieve six times a year, as specified in the Standard 36. Within the last report, there was a requirement to comply with the COSHH regulations. The manager informed the inspector that since the issue was raised at the last inspection, he had spoken to the member of staff who left the cleaning substances unattended, and had organised training sessions regarding COSHH, for all staff. Kilburn Care Centre DS0000058025.V255684.R02.S.doc Version 5.0 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 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 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 X 17 X 18 X 3 2 x X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X X Kilburn Care Centre DS0000058025.V255684.R02.S.doc Version 5.0 Page 20 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 7 Regulation 15 Requirement The registered person must ensure that care plans are up to date, to assist in the delivery of consistent care to meet the needs of service users. (A previous requirement, original timescale 11/06/05) The registered person must ensure the safety of the service users by either fitting protectors to the strip light or by replacing the lights. (New agreed timescale) 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. The registered person must ensure that staff receive the necessary training, as detailed in the body of this report. Timescale for action 11/06/05 2 19, 25 12 05/12/05 3 20 12 and 23 05/01/06 4 30 12 05/11/05 Kilburn Care Centre DS0000058025.V255684.R02.S.doc Version 5.0 Page 21 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.V255684.R02.S.doc Version 5.0 Page 22 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. 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