Inspection on 12/07/06 for Kirby House

This inspection was carried out on 12th July 2006.

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.

Other inspections for this house

Kirby House 25/06/07

Kirby House 22/08/05

Kirby House 31/05/05

Kirby House 21/01/05

Kirby House 12/10/04

Kirby House 02/02/04

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

CARE HOMES FOR OLDER PEOPLE Kirby House Kirby Lane Leicester Forest East Leicestershire LE3 3JG Lead Inspector Keith Williamson Unannounced Inspection 12th July 2006 09:00 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 Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 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. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirby House Address Kirby Lane Leicester Forest East Leicestershire LE3 3JG 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) 0116 2394286 0116 2390817 www.leicestershire.gov.uk Leicestershire County Council Social Services Mr David Dixon Care Home 40 Category(ies) of Dementia - over 65 years of age (20), Learning registration, with number disability over 65 years of age (4), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (6), Old age, not falling within any other category (40), Physical disability over 65 years of age (11), Sensory Impairment over 65 years of age (4) Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. No person falling within category DE(E) may be admitted to the home when 20 persons who fall within category DE(E) are already accommodated. No person falling within category MD(E) may be admitted to the home when 6 persons who fall within category MD(E) are already accommodated No person falling within category LD(E) may be admitted to the home when 4 persons who fall within category LD(E) are already accommodated No person falling within category PD(E) may be admitted to the home when 11 persons who fall within category PD(E) are already accommodated No person falling within category SI(E) may be admitted to the home when 4 persons who fall within category SI(E) are already accommodated Service Users Service users between the age of 55-65 years who fall within the above categories and were resident in the care at the date of registration may continue to reside there To be able to admit the person aged 55 years of age named in variation application no. 49022 dated 25th June 2003 for specific periods of respite care Service Users To be able to admit the named person aged 54 falling in category SI named in variation application number 54839 for regular periods of respite care, not exceeding 4 periods in any one calendar month. 7. 8. Date of last inspection Brief Description of the Service: Kirby House is a care home providing personal care and accommodation for forty older persons. Kirby House has a respite facility offering accommodation for three individuals, and a specialist reablement unit for offering accommodation for four individuals who need to re-gain skills before returning home. Kirby House offers a small day care service for residents living within the community and for those residing at the home. The home is part of Leicestershire County Council, and is located close to both Leicester Forest East and Kirby Muxloe. Local shops and village life is accessible, with public transport being available into Leicester City. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 5 Kirby House is a purpose built home owned by Leicestershire County Council and home comprises of 40 single bedrooms, with communal areas being provided on both the ground and first floor, with access to the first floor via stairs or a passenger lift. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation. This inspection took place over one weekday, commencing at 9.20am took seven to complete, and was assisted by the temporary manager and temporary assistant manager. An opportunity was taken to look around the home, view records, policies and care plans and to talk to fourteen residents and six staff. What the service does well: What has improved since the last inspection? What they could do better: Complaint outcomes could be followed through and written into the plans of care. Quality assurance could be enhanced and a greater use and distribution of anonymous questionnaires, and further use of resident meetings could greatly assist this process. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 7 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. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 8 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 Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 9 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, 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The content and the distribution of information is good and supports prospective residents in making a decision as to where to live. EVIDENCE: Information regarding the service and facilities, which Kirby House provides is kept on site, this details the initial assessment and referral process and includes environmental information along with the homes aims and objectives. Incorporated is information as to how complaints, comments and compliments can be raised. The information provided by Kirby House does not include views or comments of residents who already reside within the home. Residents with sight impairments may experience difficulty in reading the documentation; other formats could be considered, with consideration being given to the range of residents needs for which Kirby House is registered to provide for. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 10 Information in relation to the fees charged have been updated, as have the details of the Temporary Manager, which is significant only being in post for one week. Residents spoken with could not comment if having received any written information prior to their placements commencing. The Temporary Manager on duty confirmed that they have few direct enquires, with a majority of referrals being made through a Social Worker. The provision of information could be improved, for example if Social Workers were to provide the individual with the information as part of the assessment and referral process. The records of four residents residing at the home, all were found to contain a comprehensive assessment undertaken by a Social Worker. This home does not offer a service under Standard 6 or Intermediate Care. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 11 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are looked after well in relation to health and care needs. EVIDENCE: The care plans and records of four residents were viewed, some of these are plans containing basic information and instruction as to the care needs of the residents. Significant improvements have been made to the content of a number of care plans, since the commencement of the Temporary Manager, these being more detailed in indicating what residents current care abilities are and what specific staff input is required. Risk assessments are in place which detail as to how care is to be delivered, which promotes the health and welfare of both service user and care staff. Discussions were held with four residents whose records were not viewed, but had indicated they wished to speak with the Inspector, all agreed and stated they were happy with the level of care they received, and found staff to be caring, supportive and thoughtful in providing care in private. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 12 Records viewed indicated regular access to health care professionals, including General Practitioners, District Nurses, Chiropodists and specialist medical staff including hospital appointments. The medication and medication records of some service users were viewed; all were found to be in good order. Throughout the inspection process staff were observed speaking with service users in a sensitive manner, with consideration being given to the promotion of their privacy and dignity, staff ensured that the nursing care of a service user which was delivered by a visiting District Nurse was conducted in private. The final wishes of residents are entered into plans of care, which shows a caring attitude at this emotive time. Of the residents spoken with on the day, one stated she did not like using the toilets in the area of the office, as they “were not private enough”, no residents spoken with indicated knowledge of their care plans. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 13 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users experience a homely life style and visitors are encouraged to visit. Various activities are available to service users, service users wishing to participate in external activities do not do so at the frequency they wish. EVIDENCE: Kirby House offers a day care service for individuals living within the community; some residents residing within the care home also access this. The day care facility is staffed by Activity Organisers, employed by Leicestershire County Council. Individuals accessing the day care facility stated that they accessed the service on a part time basis, and took part in a variety of activities. Individuals accessing the day care could not confirm they are consulted about aspects of the service they receive. However residents in the main home are now consulted on various aspects of the home through questionnaires and regular resident meetings, which are assisted by a member of care staff; this is an improvement form the last inspection which recommended an increase to the frequency of these meetings. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 14 Residents were asked as to their views of meals within the home all made positive comments. Residents confirmed that they were offered choices at all meals, and that special diets were available. One commenting “I had the cheese and potato pie today, I like that”, and went on to explain she was interested in attending the forthcoming day trip out. Another resident indicated, “Meals are always good”. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 15 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 & 18. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service does not have robust arrangements in place to ensure concerns are responded to in an efficient and effective manner to protect people who use the service. EVIDENCE: Residents when asked were confident that should they have any concerns, they were clear as to whom they should speak with, in addition there is a written complaints procedure, and information as to how to contact advocacy services. Staff who were interviewed were aware of policies and procedures which detail staffs role in protecting service users from abuse, including the policies, which support staff in raising issues of concern. The Complaints Record was viewed, which evidenced that the home has had two complaints since the last inspection, both were recorded and investigated appropriately, however changes required to the care plan of a resident, stated in the outcome had not been followed through, this leaves the resident open to further neglect. The Commission for Social Care Inspection has not received any expressions of concern with regards to Kirby House. Of the residents spoken with on the day, one stated “I would see my son, if I had any problems”. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comfortable and clean standard of accommodation is provided for service users. EVIDENCE: Residents spoke positively of their environment. A comfortable and clean standard of accommodation is provided for service users. Four bedrooms were viewed by the Inspector and found to be in good decorative order, and were furnished to meet the needs of the individual and reflected their individual style, including provision of furniture and personal items provided by the service user themselves. Equipment is available to assist service users and staff in the delivery of personal care, which includes assisted baths, moving and handling equipment including hoists. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Trained and qualified staff are employed following robust recruitment checks and are employed in sufficient numbers to meet the care needs of residents. EVIDENCE: Residents are supported by four members of care staff throughout the day, with an additional one care staff supporting individuals within the day unit, in addition there is always a member of the management team on duty. Two members of care staff support residents during the night, with a member of the management team being on call. Most staff interviewed felt that staffing numbers were sufficient, and that they were able to deliver good quality and effective care. This was supported by positive comments received by service users on both the delivery of care, friendliness of care staff. The Inspector viewed a selection of staff recruitment records, all necessary employment checks, which included written references and a Criminal Record Bureau check. Staff receive regular supervision from members of the management team. Kirby House employs twenty-two members of permanent care staff, of which twelve have completed a National Vocational Qualification in Care at level 2 or 3, which represents 54 of the staff team. Three further members of care staff are currently working towards the level 2 award. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 18 In addition members of the management team also have National Vocational Qualifications in Care. The training records and training plan were viewed which highlighted a variety of topics, pertaining to the health and safety of service users and staff. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 19 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, 33, 35, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current (temporary) manager has been in post for one week, and shall continue until a permanent replacement is employed. As part of the quality monitoring process, a representative of the management team of the Local Authority, who is external to Kirby House, visits the home on a regular basis, representing the Responsible Individual. A report is generated following each visit, the purpose of the visit being to review documents, speak with residents, staff and the management team, to view the environment and deal with any specific issues. A copy of the report is forwarded to the Inspector. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 20 The quality assurance system needs further development, to formalise the process of gaining residents, their relatives or representatives views. Through this the home will be able to review its practices, to ensure its ability to continue to improve both the care and quality of life for its residents. Quality assurance processes will be followed up at the next inspection, when it is expected that significant improvements will have been made to enable residents and their representatives to comment as the services offered by Kirby House. As part of the Inspection the systems of the home were viewed with regards to involving residents in the day to day running of the home, residents were observed making day to day decisions with regards to daily living, the last residents meeting to which minutes were available was May 2005, the content of which did not indicate that resident views are taken into consideration to improve the management of the home; the further use of anonymous questionnaires and assistance of residents relatives could also inform this process. Records indicated that financial arrangements were managed in a variety of ways, by the resident themselves or by their relatives. Records of tests to fire safety equipment were in good order and health and safety issues were documented. The Fire Risk Assessment was available and had been reviewed within the previous twelve months. Generic risk assessments are in place, along with individual risk assessments for residents. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 21 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 X 3 X X N/A 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 2 17 X 18 3 3 3 X 3 X 3 X 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 X 3 X 3 3 X 3 Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 22 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. 1. Refer to Standard OP18 Good Practice Recommendations It is recommended that the complaint outcome, are actioned as agreed. Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Kirby House DS0000032927.V303205.R01.S.doc Version 5.2 Page 24 - 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. 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