Inspection on 13/12/05 for Kilkee Lodge Residential Home

This inspection was carried out on 13th December 2005.

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

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

Other inspections for this house

Kilkee Lodge Residential Home 25/09/08

Kilkee Lodge Residential Home 10/10/06

Kilkee Lodge Residential Home 17/05/05

Kilkee Lodge Residential Home 21/09/04

Kilkee Lodge Residential Home 19/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Kilkee Lodge Residential Home 297 Coggeshall Road Braintree Essex CM7 9ED Lead Inspector Kay Mehrtens Final Unannounced Inspection 13th December 2005 11:30 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 Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 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. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kilkee Lodge Residential Home Address 297 Coggeshall Road Braintree Essex CM7 9ED 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) 01376 342455 01376 342466 Kilkee Lodge Care Homes Limited Mrs Paula Jean Winestein Care Home 80 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (80) of places Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 80 persons) Two people, over the age of 65 years, who require care by reason of dementia, whose names were made known to the Commission in January 2005 17th May 2005 Date of last inspection Brief Description of the Service: Kilkee Lodge is a purpose built home for older people. All rooms are single with en-suite facilities. The home is built on two floors with a lift. It is able to meet the needs of people that require assistance with personal care and mobility. The home comprises of several lounges, dining and conservatory areas. There is a large, secure courtyard, which is decorated with tubs and provides seating for residents. The home is situated near to Braintree town centre, local amenities, shops and GP surgery. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 13th December 2005, lasting 8 hours. This was the second statutory inspection of the year and focussed on the remaining key standards not inspected at the last inspection, as well as a review of the requirements and recommendations from the last inspection. The inspection process included: discussions with the deputy manager, care staff, residents and visiting relatives. The premises were inspected, including the grounds. Samples of records and residents care plans were inspected. The outcomes of complaints received by the commission and the home are included in the report. The inspection covered twelve standards. One additional requirement was made to those not addressed from the last inspection. The home was clean and well maintained. The deputy manager and staff were very cooperative throughout the inspection. What the service does well: What has improved since the last inspection? The manager and deputy have worked well since the last inspection on improving the pre-admission assessment information gathering. The format and checklists now in place ensure an improved system for gathering the required information from the residents, their family and the placing agency. This has, in turn, led to an improvement in the care planning and review process in the home. Residents and their families are more involved in the care process. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 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. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 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 Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 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): 3. Standard 6 is not applicable. The arrangements for pre-admission assessments have improved so staff are aware of residents’ needs prior to their placement. EVIDENCE: The deputy was observed to be helpful and considerate when talking to the family of a prospective resident. Clear information about transport for the admission, contact with social services and décor and location of bedroom was given. The manager and deputy undertake pre-admission assessments. Those sampled addressed all the required areas of care and personal information about residents’ needs. The manager had introduced a clear checklist in order to ensure that all the required information was gathered. Information about prospective residents was sought from them, their family and placing agencies. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 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 The care plans had improved since the last inspection but monitoring and recording were not consistent. EVIDENCE: The care plans had improved since the last inspection. They reflected the information gathered at the assessment stage and the individual needs and wishes of the residents. There was good evidence of detailed information gathering that included the resident and their family. The format used for assessment and planning addressed all the required aspects of care and provided staff with clear actions to meet the identified needs of residents in their care. However, the staff were not gathering information from residents regarding their wishes about care and input around dying and death. The manager and deputy had introduced a monthly review checklist that ensured care plans and individual needs were monitored and updated. However, some files sampled did not contain evidence of regular monitoring of personal care needs such as bathing. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 Page 10 The daily recording, on some of the files sampled, did not reflect all the care needs of the residents concerned. The recording focused on physical needs to the detriment of the social and emotional needs of residents. This limited the gathering of information and feedback from residents and their families for reviews and specialist health appointments. Daily recording needs to be consistent across the home and to reflect the identified needs of residents, as stated in their care plans. The inspector has the opportunity to speak to a visiting district nurse who was pleased with the care and support provided at the home. They said that they had built up good links with the home and found the staff to be positive and supportive wit the residents. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 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 Residents’ choice is respected in many aspects of their life in the home. EVIDENCE: Residents were generally very positive about the variety of activities provided at the home. Though a few did say that they would like a more varied activity programme. This was also a comment made by some relatives spoken to at the inspection. Comments from residents were varied as some said that they would like some activities at the weekends and different times in the week whilst others were very happy with the activities offered. One resident told the inspector that they “enjoyed the activities especially as staff help you go out”. Lots of residents clearly enjoyed the carols and music provided by the Salvation Army during the inspection. The residents, staff and visitors all joined in with the carol singing. Residents were also looking forward to other Christmas events and said that they enjoyed all the Christmas decorations and events to date. The staff were observed to gently encourage residents to join in activities and to respect the wishes of those that did not want to participate. Residents did acknowledge that their opinions and ideas are sought at the regular resident meetings and through the recent satisfaction survey done by the manager. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 Page 12 Events and activities are displayed in communal areas for residents’ information. Though one resident did tell the inspector that sometimes the activity on offer is not always provided. The deputy did acknowledge that there had been some difficulties with activities as the home is currently one activity worker short. She said that the home was advertising for another activity worker and that staff were also offering different activities, such as film/DVD shows. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 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): 16 The home has a clear complaints procedure that is actioned in a positive manner by the manager. EVIDENCE: The home has received some complaints since the last inspection. The manager had dealt with, and upheld, a recent complaint regarding a failure by staff to ensure the safety of a residents’ whilst serving hot drinks. The manager addressed this complaint in a positive manner, meeting with the family and responding appropriately to the issues raised. Records evidenced a positive approach and balanced response to complaints. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 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): 26 Residents are provided with a safe, well maintained and pleasant home. EVIDENCE: All areas of the home were well maintained and clean. There was no evidence of any offensive odours. The home has a well-organised laundry service. Residents were pleased with the laundry service. They told the inspector that their clothes were “cleaned and pressed in a day and always returned nice”. They liked the domestic staff as they “always chat to you”. Some families choose to undertake personal laundry for their relatives though none expressed any concerns regarding the service offered at the home. Staff were observed to follow procedures with regard to infection control when assisting residents with personal care and when providing meals and snacks. The cleanliness of the hoists was inspected at this visit as a follow up to a recommendation from the last inspection. Several hoist were examined and were clean and in good repair. However, one hoist was not as clean as the rest and in need of a thorough clean to ensure good infection control procedures. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 Page 15 The inspector also noted the presence of some garden chairs in one of the lounge areas and brought this to the attention of the deputy. One of the bathrooms (hydrotherapy bath) was being used to store old furniture and equipment including the dirty hoist and excess district nurse equipment. This was brought to the attention of the deputy manager. The district nurse did inform the inspector that the excess dressings and equipment had only recently been placed in this room. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 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): 29 Staff recruitment practices are sufficient to ensure residents’ protection. EVIDENCE: The staff recruitment records were well organised and all required checks and paperwork had been undertaken by the manager, prior to any staff starting employment at the home. The deputy was aware of the need to ensure that new staff are supervised should there be any delay with their CRB check. The inspector advised that these staff have a copy of the requirements of supervised working. The staff files would benefit from better organisation and checklist to ensure that all the required information is gathered and monitored. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 Page 17 The home has employed staff from overseas. The manager and deputy had undertaken relevant checks to ensure that their understanding and use of english was acceptable for working with the residents. Residents told the inspector that they liked all the staff and only sometimes found the accents of some overseas staff hard to understand. The residents have enjoyed “teaching” the overseas staff some English words and phrases and the staff have enjoyed this interaction. The staff sat and chatted with residents over lunch and whenever they were in their company they were friendly and polite. They showed a good understanding of their care and personal needs. They were very aware of the right of residents to have access to their files. However, the inspector was disappointed to see one member of staff chewing gum whilst on duty. This is not good practice especially as it inhibits the communication and understanding of residents with hearing difficulties. This was brought to the attention of the deputy manager. Residents and visitors spoke very highly of the manager and staff at the home. The inspector had the opportunity to speak to several residents and visitors during the inspection. Their comments were positive and reflected the good practice observed. Some residents told the inspector that the “staff are lovely…their dignity is kept intact…. they were happy at the home… staff were polite”. The inspector did bring to the attention of the deputy, the failure by several members of staff to ask the inspector for identification or enquire as to the inspectors’ reason for touring the premises and reading information. The staff should be aware of the presence of any visitor to the home and if unsure ask for identification and purpose of visit to ensure the safety and confidentiality of residents. Staff training files were not inspected though some staff did inform the inspector that lots of training was provided and enjoyed by them. The deputy informed the inspector that training on many topics including health and safety, stroke care, Parkinson’s, infection control, risk assessment and communication skills had been booked for next year. This will be looked at in more detail at the next inspection. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36 and 37 Records were generally well maintained. Staff are not appropriately supervised. EVIDENCE: Standard 33 was not fully inspected, as the manager was not available to go through the outcome of the recent satisfaction survey of residents and relatives. This will be monitored at the next inspection. The records of financial arrangements and support for residents were well organised and maintained. The inspector did recommend some recording practices that would make future audits of the records easier for the administrator. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 Page 19 The deputy informed the inspector that the standard with regard to staff supervision had not been achieved. This will be monitored at the next inspection. The inspection highlighted shortfalls in some of the required records. This included daily recording and monitoring and the record of furniture brought by residents into the home. Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 2 X Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 17 Requirement The registered person must ensure that daily recording and monitoring of residents needs is done on a regular basis and reflects individual care plans. The registered person must consult with service users regarding activities and ensure that a meaningful programme is provided at appropriate times. This is a repeat requirement. The registered person must ensure that lifting hoists are cleaned regularly. This is a repeat requirement. The timescale of 19.06.05 was not met. The registered person must ensure that staff receive supervision at least six times per year. This is a repeat requirement. This standard was not inspected. The registered person must ensure that a record of furniture brought into the home by residents is maintained. The registered person must ensure that accident records are DS0000017861.V281058.R01.S.doc Timescale for action 28/02/06 2 OP12 16 28/02/06 3 OP26 16 28/02/06 4 OP36 18 28/02/06 5 OP37 17 28/02/06 6 OP38 17 28/02/06 Kilkee Lodge Residential Home Version 5.1 Page 22 cross-referenced with daily recording and monitored by staff. This is a repeat requirement. This standard was not inspected. 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 Refer to Standard OP11 Good Practice Recommendations The registered person should ensure that service users wishes regarding dying and death are recorded and that staff receive training in this subject. This is a second repeat recommendation. The registered person should develop staff training further with regard to the provision of NVQ level 2 in care in order to achieve the 50 standard. The registered person should consider the use of a checklist for staff files to improve organisation of the system. The registered person should develop the quality assurance system further, as outlined in Standard 33. This is a repeat recommendation but this standard was not inspected and will be monitored at the next inspection. 2 3 4 OP28 OP29 OP33 Kilkee Lodge Residential Home DS0000017861.V281058.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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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