Inspection on 02/08/05 for Kingfisher House

This inspection was carried out on 2nd August 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

Kingfisher House 12/01/10

Kingfisher House 22/05/07

Kingfisher House 17/05/06

Kingfisher House 25/11/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Kingfisher House 171 Yardley Green Road Bordesley Green Birmingham B9 5PU Lead Inspector Jane Walton Announced 2 August 2005 nd 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. Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kingfisher House Address 171 Yardley Green Road Bordesley Green Birmingham B9 5PU 0121 753 0333 0121 771 4190 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) Methodist Homes for the Aged Care Home 38 Category(ies) of Care Home registration, with number of places Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the Home can accommodate 38 service users who are older people (over 65 years of age) and people over 60 years of age with a terminal illness. 2. That the home can accommodate two named service users under 65 years of age who have physical difficulties.. Date of last inspection 25th January 2005 Brief Description of the Service: Kingfisher House Nursing home is a purpose built, single storey home and provides nursing care for up to 38 older people. It is situated in a residential area within the boundary of Heartlands Hospital. It is close to shops and local amenities and is accessible to public transport. The home is warm and homely and furnished to a high standard. It is very well maintained, with pleasant well maintained private gardens to the rear of the property. There are adequate parking facilities at the front of the building. Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over two days in August 2005. The inspectors were assisted throughout the process by the homes’ manager. There were 30 residents at the home, and the inspectors spoke to nine of them to obtain their views of life at Kingfisher House. Other information was gathered from conversations with six members of staff, four visitors to the home, examining care and other records, and a short tour of some areas of the home. Medication records were audited by the pharmacist inspector. This report has been delayed due to the lead inspectors extended sick leave. Subsequently, any requirements made of the home that were not immediate at the time of the inspection, have necessarily been given extended time scales. This report should be read in conjunction with the latest inspection report in order to obtain a complete overview of the service offered by this home. What the service does well: What has improved since the last inspection? The pharmacist inspectors audit of the medication management within the home indicated that there was an improvement since the previous inspection, and the new manager was keen to implement further systems to ensure the residents needs are met. Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 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. Kingfisher House E54 S63702 KingfisherHse V234690 020805 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 Kingfisher House E54 S63702 KingfisherHse V234690 020805 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) 1, 3, 5 The home requires comprehensive information to be provided for prospective residents so that they are able to make an informed choice as to whether they wish to live at Kingfisher House. Pre admission assessments and information was variable which may lead to residents being admitted to the home, when their needs cannot be met. EVIDENCE: Kingfisher House has changed ownership to Methodist Homes and a Statement of Purpose and service users guide have been produced by them, however they had not been revised to reflect the current services provided by Kingfisher House. Since the previous inspection the home has experienced a period of uncertainty and a new manager had been appointed, and been in post for only 2days when the inspection took place. Of the residents files examined, not all had evidence that a pre admission assessment had been carried out. Two files contained an assessment that was very comprehensive but had not been dated. Kingfisher House E54 S63702 KingfisherHse V234690 020805 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, 10 The arrangements for care planning and monitoring physical and emotional health were variable. This lack of consistency potentially puts residents at risk. EVIDENCE: Four residents care plans were examined and overall the general format was complicated and difficult to follow. It was very time consuming to ascertain the needs and care management required for each individual. One resident was being seen regularly by the physiotherapist for restricted movement in a shoulder, however, there was nothing in the care plan to indicate how this should be managed by care staff or that allowances must be made for the residents’ restricted range of movement. Two residents were identified as requiring pressure relieving equipment, but not which pieces of equipment should be used. One resident was being treated for 2 pressure sores. A dressing regime and body map were completed, and although serial photographs of the wounds were present, a measure guide had not been used and it was therefore impossible to gauge the size or dimensions of the wounds. One wound was referred to as a sore on the right heel, but did not state the grade of that sore, and the photograph did not reflect the true state of the wound. Although a wide range of risk assessments had been carried out, it was not always clear that they had been regularly reviewed or updated. Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 Page 10 There was evidence that residents were seen by other health professionals, including GP, Speech and Language Therapist, Optician, and Physiotherapist. An audit of the medicine administration was undertaken by the pharmacist and the following are her comments: The majority of audits undertaken were correct at the time of the inspection and this was commended. A few discrepancies were evidenced; some medicines had been administered and not recorded, others were recorded to be administered but had not been and gaps were found on the Medicines Administration Record (MAR) chart. Medicines had been administered and not recorded or not administered and the reason for non-administration not recorded. Reasons for non-administration were not always accurate. Some service users had complex medication needs and further work is required to accurately record new medicines to be administered in a clear concise way. Despite some errors found the administration and recording of medicines had improved since the last inspection and the new manager was keen to implement further systems to ensure the service users needs are met. Residents spoken to confirmed that they felt privacy was upheld, and staff knocked on doors prior to entering. However, it was felt that at times, “some staff could be abrupt and not as respectful as they ought to be” Kingfisher House E54 S63702 KingfisherHse V234690 020805 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, 13, 14, 15 Residents are generally supported to maintain social activity, contact and have their recreational needs met. Overall, meals and the mealtimes meet the basic needs of residents. EVIDENCE: There was a varied programme of activities listed in the home, and one resident commented, “There’s something to do everyday, if you want to”. On the second day of the inspection a game of Bingo took place in one of the house groups that was attended by a number of residents. One resident said that, “ Some of us went in a mini bus to the races at Wolverhampton, and some of the carers came with us to help. It was a great time.” In the sampled care plans it stated what activities were preferred by the individual resident, however, there was no record of which activities, if any, were actually undertaken. The inspectors observed care staff on several occasions sitting in the lounges with residents, but there was no evidence of any activities taking place. There were many visitors in the home with their relatives and it was confirmed that visiting is very flexible. The inspectors joined the residents for lunch on both days of the inspection. The first days lunch offered residents a starter of strawberries followed by a choice of pork and apple casserole or fishcakes, with a selection of vegetables and potatoes. One resident had a cold ham salad. A dessert of apple pie and custard or fresh fruit was available. The meal was taken in a relaxed and Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 Page 12 unrushed manner, and there were visitors in the home at the time of the meal. Residents were assisted by staff to eat their meal, where it was required. One resident said “ Sometimes the staff take me to the dining room in a wheelchair, and sometimes I walk, it depends how I feel.” On the second day, again a choice of main courses was available, preceded by a starter of melon and followed by a desert of rhubarb crumble and custard, ice cream or fresh fruit. One resident, a vegetarian, had cauliflower and broccoli in a cheese sauce. Two residents were observed being fed by carers. One residents’ meal, however, looked very unattractive, the plate being overloaded and gravy added without asking the resident if they wanted any. No assistance was offered to the resident until prompted by the inspector, and the food had gone cold. The food was then reheated and brought back. The dessert was placed in front of the same resident before she had finished her main course. This resident appeared confused and unable to ask for assistance. Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 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 standard(s) 16, 18 Arrangements for dealing with complaints were variable with the actions and outcome not documented which may lead to the dissatisfaction of the complainant. EVIDENCE: There was a complaints policy and procedure available that met the standard required, however the complaints log omitted any action taken to deal with a complaint or the outcome of any investigation. The home had an adult protection policy and procedure in place that met the standard. Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24, 25, 26 The environment in the home is generally of a high standard and provides a well maintained, safe and homely environment for the residents to live in. EVIDENCE: Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 Page 15 Kingfisher House is purpose built and suitable for its stated purpose. It is divided into three house groups, Emerald, Sapphire and Ruby, each with single bedrooms with ensuite facilities, sitting and dining rooms. A full tour of the premises was not undertaken at this inspection, however the areas and bedrooms seen showed that decoration and furnishings are generally of a high standard and there is a programme of routine maintenance and renewal. Communal areas were comfortable and homely, and the bedrooms seen contained personal items including ornaments, pictures and photographs. The assisted bathroom in House Group 3, Ruby, requires redecoration. All radiators are of the low surface temperature type. Bedroom doors were fitted with a suitable privacy lock and also have an automatic closure in the event of a fire. This ensures the safety of the residents should they wish to have their bedroom door open whilst in bed. The door to the laundry was not locked and was not in use at the time, which poses a potential risk to residents. Two of the bedrooms inspected smelt unpleasant, and measures need to be taken to remedy this. All other areas of the home seen, appeared clean and there were no unpleasant odors. Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 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 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, 28, 29, 30 Staffing levels are generally adequate to meet the needs of the residents. The home must improve on the standard of it’s recruitment procedure thus ensuring the safety of the residents. Although most staff have received appropriate training in order to carry out their duties to ensure residents are protected, and cared for appropriately, supervision is required to ensure that the training is applied. EVIDENCE: Staffing rotas indicate that there are 2 RGN’s and 7 carers on duty between 8am and 2pm, and 2 RGN’s and 6 or 7 carers from 2pm until 8pm. In most cases the second RGN is the deputy manager who is currently not supernumerary. Night staffing is 1 RGN and 3 carers. The home has a full time and a part time cook and a part time kitchen assistant. There are 3 housekeeping staff on duty Monday – Friday, and 2 at the weekends. 2 part time staff work in the laundry, and there is a full time administrator. Rotas supplied by the home suggested that relief staff, including agency, were used routinely for both nurse and carer cover. There were currently full time vacancies for both trained and care staff. Information provided indicates that there are 71 of the care staff who have been trained to NVQ level 2 which is commended. There was a training schedule and a matrix that identified what training staff had received and also identified when statutory training was due. This indicated that the majority of staff had undertaken up to date statutory training in Fire Safety and moving and handling. Training needs were identified from the following comments from staff, residents and some visitors that included “ Some staff can be a bit abrupt and don’t take enough time with Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 Page 17 residents”, and “ I’m sometimes just given a wash rather than a shower, as it’s quicker for them”. There was no formal induction programme in place and staff had not been receiving regular documented supervision. Staff files were sampled and varied in the quality of the content. One was found to have an incomplete work history with a reference for employment not listed on the form, and another not to have a completed health questionnaire. Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 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 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, 36, 37, 38 The management of the home has undergone changes in the last year and new systems being introduced must be shared with the staff group to ensure safety of the residents. EVIDENCE: There has been a change of ownership to Methodist Homes, and a new manager in post from 1st August 2005. The manager has worked within the environment of caring for elderly people for several years, but has been in post for too short a period to make a judgement on his management capabilities. The previous manager held residents meeting that were minuted, however the last one was held at the end of May 2005, so need to be recommenced as soon as possible. The last documented staff meeting was dated 30/6/04, and although staff stated that meetings have been held since that date, there was no documentation to support this. As the home had so recently changed ownership, not all records, and not all policies and procedures were properly in place. There was no formal induction Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 Page 19 programme in place and staff had not been receiving regular documented supervision. Records of servicing, testing and maintenance in respect of health and safety for utilities, appliances and equipment such as electricity, gas, and hoists are well maintained. Most are completed in a timely fashion to promote health and safety. However, the records indicated that staff are not attending 2 fire drills a year, and the fire alarm tests that should be carried out weekly are being done on a monthly basis. Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 2 x 3 x x 2 2 2 Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 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 OP1 Regulation 4(1) Requirement The home must revise its statement of purpose and service users guide so as to provide the detail required by schedule 1 of the Care Homes Regulations 2001 and reflects the homes Registration Certificate and its Conditions of Registration. A copy of the revised documents must be forwarded to the Commission for Social Care Inspection (CSCI). The home must ensure that a comprehensive pre admission assessment is carried out for all prospective residents, and a record maintained in the residents file. This requirements was left as an immediate requirement at the time of the inspection. All service users care plans must accurately reflect the current needs of the service users. (Outstanding since Jan 05) Regular staff drug audits must be undertaken to confirm staff competence in medicine management and to ensure staff Timescale for action 28/2/06 2. OP3 14(1)(a) 3/8/05 3. OP7 15(1) 30/9/05 4. OP9 13(2) 9/8/05 and ongoing. Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 Page 22 take full responsibility for the administration and recording of medicines This requirement was left as an immediate requirement on the day of the inspection. 12(4)(a) The acting manager must ensure that all staff treat residents with respect at all times. 15(1) The acting manager must ensure that all activities undertaken by the residents are recorded in their care plan. 17(2)Sche The acting manager must ensure dule 4 that the complaints log records (11) the action taken and the outcome of all complaints received by the home. 16(2)(k) The acting manager must ensure that arrangements are made to deal with the offensive odours in the two identified bedrooms. This requirement was left as an immediate requirement on the day of the inspection. The acting manager must ensure that all staff fully complete an application form, and any gaps in employment are explored. Referees given should be reflected as previous employers. This requirement was left as an immediate requirement on the day of the inspection. 10. OP30 12, 18 The acting manager must ensure that there is an induction training programme in place for all new staff. The acting manager must submit an application to register with the CSCI. The acting manager must ensure that all staff receive formal documented supervision at least 28/2/06 5. 6. OP10 OP12 3/8/05 and ongoing. 3/8/05 and ongoing. 3/8/05 and ongoing. 7. OP16 8. OP26 3/8/05 and ongoing. 9. OP29 Schedule 4 (6) 19(4)(c) 3/8/05 and ongoing. 11. 12. Op31 OP36 9(2)(1) 18(2) 28/2/06 28/2/06 Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 Page 23 6 times per year. 13. OP37 13(4)(c) All new policies and procedures 28/2/06 must be discussed with the staff group and evidence must be retained. The acting manager must ensure 28/2/06 that fire alarm tests are carried out weekly and documented, and that all staff attend fire drills every six months. 14. OP38 23(4)(c) (iii)(v) 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. 2. 3. Refer to Standard OP7 OP7 OP7 Good Practice Recommendations It is recommended that when photographs are used to monitor the progress of wounds, a measure guide is used. When it has been identified that a resident requires a hoist for moving and handling purposes, the size of the sling to be used should be recorded in the care plan. It is recommended that the type of pressure relieving equipment required for an individual resident is documented in the care plan. Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Birmingham and Solihull Local Office 1st Floor, Ladywood House 45/46 Stephenson Street Birmingham, B2 4UZ 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 Kingfisher House E54 S63702 KingfisherHse V234690 020805 Stage 4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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