Inspection on 19/07/05 for Kilpeacon House

This inspection was carried out on 19th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kilpeacon House 16/04/08

Kilpeacon House 26/04/07

Kilpeacon House 16/06/06

Kilpeacon House 11/01/06

Kilpeacon House 17/01/05

Kilpeacon House 21/06/04

Kilpeacon House 17/01/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Kilpeacon House Grey Road Altrincham Cheshire WA14 4BU Lead Inspector Michelle Moss Unannounced 19 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kilpeacon House Address Grey Road Altrincham Cheshire WA14 4BU 0161 928 2784 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr James Skeath Mrs Lina Margaret Skeath Mrs Dianne Joan Chapman CRH Care home PC Care home only 24 Category(ies) of OP Old age registration, with number DE(E) Dementia - over 65 of places Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: All service users will be aged 65 or over. Service users will require care by reason of either old age or dementia and may in addition have a physical disability. Date of last inspection 17 January 2005 Brief Description of the Service: Kilpeacon is a care home providing personal care and accommodation for 24 service users of pensionable age (65 and over). It is owned by Mr. & Mrs. Skeath. The home is located in an established residential area of Altrincham, close to shops, bus and train routes and other amenities. The home is a detached two-storey building comprising of 14 single and 5 double bedrooms. En suite faculties were available in most rooms. There is a dining room, lounge with dining area and a conservatory. A passenger lift is available to the second floor. The home has gardens to front and rear. Parking is available to the front of the premises. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the home’s first annual unannounced visit for the year, which took place over 3.5 hours during a weekday in July. A number of residents were met of which two were consulted over their experiences of life at the home. 3 staff were on duty plus the manager. The main focus of the inspection was on the care of residents, care planning and management systems operated within the home. The users of the service and the staff were consulted over the term of address preferred in writing this report regarding the users of the service. It was indicated that the preferred address was “residents”. The inspection only looked at a limited number of standards, so this report should be read together with the earlier report to get a full picture of how the home is meeting the needs of the residents living there. What the service does well: What has improved since the last inspection? Training had been given a high priority by the home. The staff had attended a number of key training courses that were important to inform staff about care practice and meeting residents care needs. This assisted staff to have the competence to respond to the changing needs of residents and make appropriate referrals to health professionals. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 6 The home had developed their care planning system. The improved system was focused on the residents and instructed staff on the way the residents wished their care needs to be met. The home’s recruitment of staff had been improved making sure staff were suitable for working with vulnerable adults. Medication was being well managed with a competent staff undertaking the administration of medication. The housekeeping hours in the home had increased which meant the care staff had more time to spend with residents. 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. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 & 3 Prospective residents benefited from a structured admission procedure. EVIDENCE: The home’s manager had taken the lead in developing more detailed assessment tools that were aimed at improving the process of determining the assessment of needs for prospective residents. Obtaining other professional assessments were included in the process which helped the home to ensure all prospective residents were only admitted after it was identified the home had both the skills and staffing to meet the care and health needs of the new resident. The home had improved their contract between themselves and residents by including details on the room to be occupied. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 9 The residents’ care and health was well documented by the home. This included having a well-managed system in place for medication and health conditions affecting the residents. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 10 EVIDENCE: A sample of the service users plans were seen. These were well maintained with a summary at the beginning of the plan that informed on the care needs of the resident. This instructed the staff on the level of support required and why. The records being maintained gave information that showed the home ensured they were meeting the changing needs of residents due to illness and frailty. A hospital admission transfer care plan had been introduced that informed the hospital of essential health information about the residents. Good use of weight, dietary monitoring and body mapping charts showed that the home ensured the overall health and welfare of residents were been monitored. The risk assessment process was comprehensive and resident specific. All aspects of the care plan was reviewed on a regular basis. Residents had a care plan specific to their medication. These were found to be detailed. The records for administering medication were overall well maintained. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 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 standard(s) 12 & 15 A range of meaningful activities was provided by the home that matched the residents’ social, cultural, religious and recreational interests and needs. EVIDENCE: Through talking with residents, looking at the home’s activity diary and residents care plans it was seen that a varied range of activities were being provided by the home. Some were small scale activities completed with staff in an informal way such as manicuring, playing cards, sing a longs, indoor bowls and skittles. Other activities were more planned including artists, flower arrangements and church services. Two residents said that the meals were very good. The lunch served was well received by residents with nearly all residents eating the whole meal. In a dignified manner staff were supporting residents who required support with eating their meal. This was done on a one to one basis at a pace determined by the resident. The cook maintained contact with the residents to ensure the meals served reflected the residents likes. If concerns over dietary intake were raised a procedure was used that set out guidelines of the steps staff were to take to ensure a residents nutritional needs were not compromised. All residents benefited from having included in their care plan a nutritional screening assessment. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 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 standard(s) 16 & 18 The complaints process in the home was good and vetting and recruitment practices had improved, providing safeguards to protect residents. EVIDENCE: Training in Adult protection had been booked. The induction of new staff included a section on Adult protection and whistle blowing procedures. The Commission of Social Care Inspection (CSCI) investigated a complaint about some aspects of care practice at the home. This identified some weaknesses in the care of residents of which requirements were made at the time of the investigation. These were actioned by the home in a timely manner that addressed all the concerns raised. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 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 standard(s) 19, 20, 24, 26 The overall quality of the furnishings and fittings are good. However, some aspects of residents’ health and safety were being compromised by the use of certain key locking devices, a broken wardrobe and the inadequate infection control being operated in the home. EVIDENCE: A sample of bedrooms were seen, which were found to be clean and tidy. Furniture was colour co-ordinated and residents were given the opportunity to bring in personal belongings. However, one room seen had a broken wardrobe of which one door had been removed for safety. The remaining door was dislodging from the runner and on contact moved, which caused a potential safety risk. Some of the bedrooms doors were fitted with a Yale lock device, which could not be overridden in an emergency. These locks were required to be changed to a more safe locking system. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 14 New seating had been purchased for the communal areas adding additional comfort. On entering the home an unpleasant smell was present in the entrance hall. This was discussed with the manager. The smell did not appear to be an incontinent smell but the cause was not known. The manager said there had been a re-occurring water leakage problem in the roof space which had resulted in rainwater coming through the ceiling resulting in the area becoming wet. The cause of the smell must be investigated and treated accordingly. The laundry facilities had improved which reduced errors occurring with residents clothing going to the wrong room. The staff had received training in infection control. Through this it was identified that staff were not always getting access to all the equipment necessary to help them complete their care tasks in a safe and hygienic way. Concerns extended to staff not having access to gloves including none powder gloves, paper towels and appropriate aprons and cloths. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 The amount of training completed by staff was at a high level resulting in a competent, and enthusiastic workforce that had the skills to protect the health and well-being of residents. EVIDENCE: Three care staff and the manager were on duty to 24 residents. In addition there was a housekeeper and cook on duty. In recent times the number of hours allocated to house keeping had increased covering 7 days out of 7. This had released time back to the care staff to give more time to care and social activity with residents. The general cleanliness in the bedrooms had appeared to improved as a result of the additional cleaning hours. The residents spoken with said that staff were very good, kind and caring. A high priority had been given by the home to training in the past 6 months. The level of training attended by staff was commendable. The training was specific to the welfare and healthcare of residents and had instructed staff on important information that helped them to be more competent in meeting the needs of residents. Staff were supported by the home to complete their NVQ awards. At the time of the inspection over 40 of staff held a NVQ qualification with others registered on the award programme. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 16 A record of staff training was being held that showed the number of staff who had completed NVQ training exceeded the minimum stated in the National Minimum Standards. The manager had actioned concerns raised at the home’s last inspection regarding the recruitment of staff. The application form and the procedures for obtaining references had been improved. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33 and 38 The residents benefited from a well run home, with a manager who through developing the care planning system was promoting the health of residents. However, the residents’ welfare and safety were being compromised by the lack of fire safety monitoring systems being operated in the home. EVIDENCE: The residents spoken with said the manager was good and were seen to be at ease. A relative confirmed they felt able to raise any concerns with the manager and said they were appropriately addressed. A previous concern raised over the monitoring and testing of fire safety was followed up. A diary had been started for recording testing and checks. However, this was not being maintained and did not give a full detail of the testing and checks completed, which confirmed the fire system in the home was fully operational to safeguard the residents’ safety. The previous requirement was therefore reiterated. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 2 x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 x x x x 2 Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 19 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. Standard 26 24 24 38 26 Regulation 16 13 13 23 13 Requirement A odour in the enterance hall must be investigated and the smell elimanated . Yale Locks must be removed and replaced with locks that cannot be locked from the inside. A broken wardrobe must be repaired. Fire safety. Timescale for action 30.08.05 30.09.05 30.08.05 30.08.05 The infection control measures in 30.08.05 the home must ensure preventive measures are operated to reduce the spread of infection including:Having a stock of gloves and aprons in the home at all times. Gloves should be non powdered and ideally latex free. Gloves should be available in each room at the point of care. A stock of paper towels must be situated in the home at all times. Coloured cloths must be used for cleaning different areas of the home. All these items must be accessible to staff 24 hours a day. Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 20 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 Good Practice Recommendations Kilpeacon House F55 F05 s5618 kilpeacon house v229217 070605 stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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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