Inspection on 22/08/05 for Kirby House

This inspection was carried out on 22nd August 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kirby House 25/06/07

Kirby House 12/07/06

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 Linda Clarke Unannounced 22 August 2005, 9:30am 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. Kirby House C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Kirby House Address Kirby Lane Leicester Forest East Leicestershire LE3 3JG 0116 2394286 0116 2390817 None Leicestershire County Council Social Services 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 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 C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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 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 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. Date of last inspection 31st May 2005 Kirby House C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 Page 5 Brief Description of the Service: Kirby House is a care home providing personal care and accommodation for forty older persons, and offers three respite places. Kirby House also has a rehabilitation unit offering accommodation for four individuals who need to regain skills before returning home. The forty single bedrooms are withou ensuite facilities. The home has a large garden to which residents have access. The presmise is owned by Leicestershire County Council Social Services Deparment, 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. The home is accessible by private of public transport. Kirby House is fully accessible 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 C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection took place between 9.30am and 2.30pm. The opportunity was taken to look around the home, spend time with residents, view records and policies which, included viewing the care plans of three residents residing at the home, and one individual accessing the rehabilitation unit. Information recorded on the pre-inspection questionnaire has been incorporated into the Inspection Report What the service does well: What has improved since the last inspection? What they could do better: Care plans could further be developed to contain greater detail as to the resident’s mental health, and how this impacts on their daily lives, and the role of care staff in supporting them. Care plans could further be improved by incorporating social interest, hobbies and recreational pursuits of residents. Residents would benefit from a comprehensive daily record being completed by care staff, which reflects there identified needs and incorporates daily social activities. Staff if they were to access training in care plan and report writing along with medical conditions including mental health, to which residents are diagnosed, would be able to offer a more tailored approach to individual care, and state how this could should be delivered within the care plan. Kirby House C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 Page 7 Residents should be encouraged to comment on the management of the home, the ways as to the achievement of this should be considered, but could include the increase in frequency of resident meetings. The process for the recording and investigating of concerns should be reviewed to ensure transparency. 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 C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Kirby House C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 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 standard(s) 1 and 3. The admission process is well managed with residents needs being assessed ensuring staff have the appropriate information to meet individual needs. EVIDENCE: Kirby House has a Statement of Purpose, which outlines the care and accommodation offered to residents, arrangements for staffing including staff training, the daily living arrangements offered to residents including information on mealtimes. A separate booklet is available for those individuals accessing the rehabilitation unit. As part of the assessment process residents and relatives are asked to provide a history of their life prior to admission, this provides additional information to help in the delivery of care and activities provided. Information supplied could be used to a greater advantage in the developing of resident care plans. Kirby House C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 Page 10 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 and 11. Residents are looked after well in respect of their health and personal care needs. EVIDENCE: Care plans of three residents’ were viewed, which contain an outline of resident needs. Care plans could be further developed to encompass a comprehensive record of resident needs, with consideration being given to mental health and socialisation including hobbies and interests, thus providing a holistic approach to care. Care plans detailed information as to resident’s health care needs, including specific information pertaining to illness and death, where indicated by residents and/or relatives. The records of one individual accessing rehabilitation was viewed, these contained assessments and an individual plan of care, which detailed goals, needed to be achieved, consistent with independent living. Records evidence regular contact with health care professionals where appropriate. The Inspector spoke with three members of care staff, who were aware of the individual needs of residents. Kirby House C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 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) Standards within this section were not inspected on this occasion. EVIDENCE: Kirby House C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 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 and 18. Residents are not fully protected by the practices of staff within the home. EVIDENCE: Kirby House has received two minor complaints this year, the complaints and the outcome of investigations was documented. The Commission of Social Care Inspection has not received any complaints in relation to Kirby House. Kirby House has a copy of the Department of Health’s Guidance on the Protection of Vulnerable Adults from Abuse. The Inspector noted within the daily records of one resident, concerns that had been raised by relatives as to comments the resident made directly to them, on two separate occasions. A member of the management team had investigated the concerns, however no documentary evidenced supported the investigation process, which included the interviewing of staff. It could not be determined at the time of the Inspection as to whether the comments made by the relatives had been passed on to senior management of Social Services or a Social Worker for consideration consistent with the Department of Health’s Guidance ‘No Secrets’. Kirby House C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 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, 23 and 26. A comfortable and safe standard of accommodation is provided for the resident’s including a garden area, which individually and collectively meets the resident’s needs. EVIDENCE: Kirby House is well maintained and is suitable to the needs of residents; areas identified at the previous inspection for decoration have yet to be addressed, however quotes have been obtained identifying the work to be carried out. The Inspector viewed the bedrooms of individuals whose records and care plans were read, all were found to be homely and met the needs of individual residents. Kirby House C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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) 28, 29 and 30. Recruitment procedures are robust, and staff receive training relevant to residents health and safety. EVIDENCE: Kirby House employs twenty-three members of care staff of which thirteen have attained a National Vocational Qualification; this level of achievement is to be commended. The staff files of two members of staff employed this year were viewed, and were found to contain all relevant documentation including a Criminal Record Bureau check. Staff have received training in a variety of topics, including fire awareness, moving and handling and first aid to name some. Staff have also received training in specialist areas such as Parkinson’s disease and Dementia. Staff spoken with had a clear understanding of resident needs, and confirmed they were responsible for the devising and reviewing of care plans. Staff had not received formalised training in care plan writing. The Departmental Training Plan details training available to care staff in care plan and record writing and medical conditions including physical and mental health. Care staff should therefore be encouraged to access these courses to increase their awareness and develop resident care. Kirby House C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 Page 15 The Inspector discussed with the three care staff interviewed, the use of care plans and daily records and how these could be developed to encompass all aspects of care, and contain a greater level of detail and information. Kirby House C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 Page 16 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) 33 and 35. Residents are not fully supported in affecting the way in which the home is managed. EVIDENCE: 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, however the last resident meeting to which minutes were available was September 2004, which suggests that resident views are not canvassed in order to continually improve the management of the home. Records indicated that financial arrangements were managed in a variety of ways, by the resident themselves or by their relatives. Kirby House C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x 3 x x 3 STAFFING Standard No Score 27 x 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 2 x 3 x x x Kirby House C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 Page 18 No 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. 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 7 Good Practice Recommendations It is recommended that care plans contain additional information, evidencing an holistic approach to care. 1. Mental Health and its affects on the individual to be more detailed. 2. Recreational and activities form part of the care plan. 3. Daily records contain more detailed information, indicative of their care plan. The process for the recording and investigating of concerns should be reviewed to ensure transparency. It is recommended that access training in care plan writing and medical conditions, including mental health and dementia as detailed within the Departmental Training Plan. It is recommended that the frequency of resident meetings is increased, and other forms of inclusion for residents in voicing their views be considered, consistent with the standard. 2. 3. 18 30 4. 33 Kirby House C51 C01 S32927 Kirby House V242503 220805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire 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. 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