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Inspection on 28/10/05 for Kilfillan House Nursing Home

Also see our care home review for Kilfillan House Nursing Home for more information

This inspection was carried out on 28th October 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The standard of care and services in this home has gone from strength to strength. The staff interacted well with the service users and their family and among themselves. One service user said "I am perfectly satisfied with the care and service given here. I have no complaints". One relative commented "This is a cheerful place. It is like a home rather then a nursing home."

What has improved since the last inspection?

The care home has appointed one of its senior nurses as the new deputy manager to fill the vacant position. A new chef has been appointed since the last inspection. The access to the lift has been changed. There are now two exit doors to the lift on the first floor rather then one.The Continuing Care Service Arrangement with the local Hospice of St Francis is working well. The specialist doctor from the Hospice visits three times a week. These visits help ensure a high quality service to those service users requiring palliative care.

What the care home could do better:

The care home is currently without an activity co-ordinator. However, there are a number of applicants waiting to be considered. Meanwhile, the nurses and carers continue to organise the activities and to ensure that the social and recreational needs of the service users are not affected.

CARE HOMES FOR OLDER PEOPLE Kilfillan House Nursing Home Graemsdyke Road Berkhamsted Hertfordshire HP4 3LX Lead Inspector Yoke-Lan Jackson Unannounced Inspection 28th October 2005 16:00 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 Kilfillan House Nursing Home DS0000019442.V261001.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. Kilfillan House Nursing Home DS0000019442.V261001.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kilfillan House Nursing Home Address Graemsdyke Road Berkhamsted Hertfordshire HP4 3LX 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) 01442 877 115 01442 877 598 springc@bupa.com BUPA Care Homes Limited Mrs Caroline Spring Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32), Physical disability (5), Terminally ill (1), of places Terminally ill over 65 years of age (10) Kilfillan House Nursing Home DS0000019442.V261001.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. This home may accommodate up to 10 service users who are terminally ill. This home may accommodate 32 older people who require nursing care. This home may accommodate 5 people (aged 50 or more) in need of convalescent nursing care. This home may accommodate 5 people (aged 50 or more) with physical disability who require nursing care. The home may accommodate one named service user who has not yet attained the age of 65 years, under the category of TI 21st April 2005 Date of last inspection Brief Description of the Service: Kilfillan House, operated by BUPA Care Homes Limited, is a Nursing Home for 32 elderly service users. The home is registered for nursing and the terminally ill category, physical disabilities (5) and convalescence (5). The building is situated in a quiet residential road about half a mile from the town centre of Berkhamsted. The front of the building is mainly used as a parking area boarded by some mature border plants and trees. There is limited space to the back of the building since part of the ground was sold off. There are ample parking spaces on the main road. The entrance leads to a large reception area, the dinning room and the kitchen. The administrative office is to the side of the reception area. The nurses station has been moved to a more spacious room on the first floor. The bedrooms are of single-occupancy with en-suite toilet facilities. They are situated mainly on the first floor. However there are a number of bedrooms on the ground floor on one side of the building. There are a number of assisted bathrooms and toilet facilities within easy reach. The home has a lounge that leads to a large conservatory that is being used as a second lounge/activity room. The conservatory leads to an average size garden with seating areas for the service users and visitors. Part of the garden has been developed into a Sensory Garden that is now in full use. Kilfillan House Nursing Home DS0000019442.V261001.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out on 28/10/2005. The registered manager and the new deputy manager were present. There were 30 service users in the home on the day of the inspection. The inspection was conducted in the late afternoon. Several service users and their family members were interviewed. General observation was made of the staff performance and interaction. Written records and care plan files were examined. The service users appeared well cared for. Their comments about the care and service provided were all positive. The home has received several complimentary letters from relatives. (Please see below for the details of the inspection findings). What the service does well: What has improved since the last inspection? The care home has appointed one of its senior nurses as the new deputy manager to fill the vacant position. A new chef has been appointed since the last inspection. The access to the lift has been changed. There are now two exit doors to the lift on the first floor rather then one. Kilfillan House Nursing Home DS0000019442.V261001.R01.S.doc Version 5.0 Page 6 The Continuing Care Service Arrangement with the local Hospice of St Francis is working well. The specialist doctor from the Hospice visits three times a week. These visits help ensure a high quality service to those service users requiring palliative care. 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. Kilfillan House Nursing Home DS0000019442.V261001.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 Kilfillan House Nursing Home DS0000019442.V261001.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): 1, 2, 3, 4. Prospective service users have the information they need to make an informed choice and information is made available through a variety of means. The management implements a thorough admission process. The staff, individually and collectively, have the skills and experience to deliver the services and care which the home sets out to provide. EVIDENCE: The admission notes and the care plan files of the service users examined confirmed that a full assessment was carried out before a prospective service user was admitted into the home. Each service user has a copy of the signed written contract and the Service User Guide on admission. There is one emergency bed for immediate admission (without the service user having to go through the hospital admission process). Appropriate preadmission assessment is maintained. Kilfillan House Nursing Home DS0000019442.V261001.R01.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): 7, 8, 9, 10, 11. Service users are treated with respect and dignity. Their right to privacy is maintained. The care planning system ensures that service users’ needs are met in an appropriate way. The administration of medication is in accordance with legislation. EVIDENCE: The members of staff were observed to interact very well with the service users and their relatives. One relative remarked that the home is “a cheerful place” and that the staff are “incredibly kind.” The service users appeared relaxed and content. Only complimentary remarks were made. One service user said “ I am perfectly satisfied with the care given”. Kilfillan House Nursing Home DS0000019442.V261001.R01.S.doc Version 5.0 Page 10 The care plans examined have detailed accounts of the healthcare and personal needs of the respective service users. It was evident that care plans are maintained and regularly updated. The service users and their relatives are involved in the plan of care. The home has good rapport with the various healthcare and specialist professionals. The specialist doctor from the Hospice of St Francis visits all service users requiring palliative care. These visits help ensure a high quality service to these service users. The Hospice provides training to staff in palliative care. They also support the service users and their family. Kilfillan House Nursing Home DS0000019442.V261001.R01.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): 12, 13, 14, 15. The service users are given the opportunity to participate in all aspects of routine living. They are given choices and their preferences are respected. The service users are encouraged to maintain links with family and friends. The meals provided are nutritious and balanced and choices are given. EVIDENCE: The service users are encouraged to exercise choice and control over their lives. The nurses and carers continue to maintain the activity programmes whilst the post for an activity co-ordinator remains vacant. There are currently a number of applicants waiting to be considered. The service users spoken to said that they are pleased with the catering in the home and that they have no complaints about the menu. The care home has appointed a new chef since the last inspection. Kilfillan House Nursing Home DS0000019442.V261001.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. There is a complaints process that all service users can access, both formally and informally. Staff have the appropriate training to ensure that service users are protected from abuse. The service users’ legal rights are protected. EVIDENCE: There has been no incident of abuse or complaint since the last inspection. The home follows the Hertfordshire Adult Protection Policy and Procedure. Staff interviewed are cognisant of the Whistle-Blowing Process. Kilfillan House Nursing Home DS0000019442.V261001.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Kilfillan House is homely, clean and a safe environment for the service users. The buildings and the surrounding grounds are well maintained. EVIDENCE: The premises appeared tidy and well maintained. The bedrooms inspected appeared comfortable, neat and clean. The service users spoken to said that they are very pleased with their bedrooms and the facilities provided. The items displayed reflected their individual lifestyles. The linen cupboard next to the lift on the first floor has been removed to allow for two exit doors for the lift instead of one. The lift was in operation on the day of the inspection. Kilfillan House Nursing Home DS0000019442.V261001.R01.S.doc Version 5.0 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 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, 28, 29, 30. The home has an effective and dedicated team of nurses, care workers and other supporting staff. They have good knowledge of the health and assessed needs of the service users. The training programme for staff is structured and consistently maintained. The recruitment process is thorough and complies with legislation. EVIDENCE: All the staff have demonstrated their dedication to their work in caring for the service users in the home. This was further evident by the complimentary remarks received from all the service users and relatives interviewed during the inspection. One relative said: “The staff are caring. They also get on well with each other.” The members of staff present confirmed that they are given opportunities to attend external and in-house training programmes. A number of applicants for the vacant position of activity co-ordinator are currently going through the recruitment process, which is thorough and in line with legislation. Kilfillan House Nursing Home DS0000019442.V261001.R01.S.doc Version 5.0 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 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, 34, 35, 36, 37, 38. The care and services provided continue to be of a high standard. The home is run in the best interests of the service users. Their health, safety and welfare are promoted and protected. EVIDENCE: The administration and management of the home are consistently well maintained. The management approach creates an open, positive and inclusive atmosphere. This is further evidenced from the complimentary feedback (both written and verbal) the home received from service users’ family members. The family of one service user remarked that the registered manager is “approachable and nothing is too much for her.” They are very happy with the care and services given. The records for the protection of service users are maintained and used in accordance with the Data Protection Act 1998. Kilfillan House Nursing Home DS0000019442.V261001.R01.S.doc Version 5.0 Page 16 The home has its own internal audit through Residents’ and Relatives’ meetings and written questionnaires and feedback. There is an annual audit of services by the provider, BUPA. Kilfillan House Nursing Home DS0000019442.V261001.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 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 3 3 3 3 3 3 3 Kilfillan House Nursing Home DS0000019442.V261001.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 Kilfillan House Nursing Home DS0000019442.V261001.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Kilfillan House Nursing Home DS0000019442.V261001.R01.S.doc Version 5.0 Page 20 - 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!