Inspection on 25/06/07 for Kirby House

This inspection was carried out on 25th June 2007.

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 12/07/06

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 Rajshree Mistry Key Unannounced Inspection 25th June 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kirby House DS0000032927.V339919.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.V339919.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 Ms Karen Winder Care Home 40 Category(ies) of Dementia - over 65 years of age (8), 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 (8), Old age, not falling within any other category (40), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (4) Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following categories of service only:Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home fall within the following categories: Old Age, not falling within any other category - Code OP (40) Dementia - Code DE (8) Mental Disorder - Code MD (8) Learning Disability - Code LD (4) Physical Disability - Code PD (8) Sensory Impairment - Code SI (4) 2. The maximum number of service users who can be accommodated is 40. Date of last inspection 12th July 2006 Brief Description of the Service: Kirby House is a care home providing personal care and accommodation for forty older persons. 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 is a purpose built home and 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 has a respite facility offering accommodation and a specialist re-ablement 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. Information about Kirby House and the range of service offered is detailed in the Statement of Purpose. Copies of the Commission of Social Care Inspections, Inspection Reports, are located in the main office and entrance hall and are available upon request. The maximum weekly fee is £476.00, which was provided on the day of the Inspection. There are additional costs for individual expenditure such as Chiropody, Optician and hairdressing services, and the fee will depend on the services received. Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, which included viewing the last Inspection Report, reviewing and gathering of evidence from the Annual Quality Assurance Assessment (AQAA) – the Provider’s self assessment, and reviewing the service history of significant events since the last inspection. Comment Cards were sent from the Commission for Social Care Inspection to ten residents who were identified in the AQAA. The unannounced site visit commenced on the 25th June 2007 and lasted 1 day. The focus of the inspection is based upon the outcomes for the residents. The method of inspection was ‘case tracking’. This involved identifying residents with varying levels of care needs and looking at how these are being met by the staff at Kirby House. Three residents were selected and discussions were held with them. Discussions held and observations were made of other residents and visitors who were not part of the ‘case tracking’ process. The method of case tracking included the review of residents’ individual care records, discussions with staff with various responsibilities within the home and reviewing the records, training records and the minutes of team meetings. The CSCI sent out ten Comment Cards to residents, of which 60 were returned. All the responses were positive about the care provided at Kirby House and the home environment. The CSCI sent out ten Comment Cards to relatives of residents at Kirby House, of which 20 were returned. Comments incorporated within Service Users Comment Cards and direct comments included: “Likes living at Kirby House, feels it is the right place for him” “I get my say and have things done how I like it” “I have no complaints” “The only way improvements could take place for a higher standard would require more staff and money. Excellent well managed service” “Very pleasant staff, officers, carers and domestic staff” Comments incorporated within Relatives Comment Cards included: “No improvements required – essential that it is allowed to carryon with the good work for many years to come” “Everything – by far the best home in the country for my mother” Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 6 “Fantastic communication and support for me as well as my mother” “The general atmosphere is one of contentment and safety with concerted efforts made for residents to do as much as possible for themselves with careful support” “A well managed home making an effective and safe environment for vulnerable elderly people who experience a homely and supportive place for their final years”. What the service does well: What has improved since the last inspection? Environmental improvements have taken place: decoration and furnishing of four bedrooms, dining room and lounge. Improvements have been made to the bathing facilities and externally to the garden. The recommendation made at the last inspection have been addressed as good practice and evidenced during the site visit. The Registered Manager successfully underwent the ‘fit person’ process with Commission. The Statement of Purpose has been updated to reflect the experience and qualifications of the Registered Manager. Care plans have significantly improved, personalised using a ‘person centred approach’ to meet the needs of the residents, with consideration to their Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 7 preferences, rights and choices. Where possible, relatives are also involved in the development of the care plans. Kirby House carried out a quality assurance survey and the results of the findings are being addressed to benefit the people living there. 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. The summary of this inspection report can be made available in other formats on request. Kirby House DS0000032927.V339919.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.V339919.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 and 6. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are provided with clear and up to date information about the service; are involved in the assessment process that ensures their care needs are met. EVIDENCE: People considering residential care at Kirby House are provided with a ‘Customer Care Pack’. This contains in information about what services are provided; long stay, short stay, day care and the Community Re-ablement Service at Kirby House and the assessment process and moving to the home. There is information about the accommodation and provisions such as meals, visiting arrangements; social and recreational activities; the process of raising concerns, complaints or commendations and how the residents are consulted and involved in the running of the home. Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 10 The Customer Care Pack is provided to residents when they move to Kirby House or at their first visit and a copy is on display at all times in the reception area. The information is comprehensive and the format is in easy to read style. The information is also provided in other formats and languages. The records of three residents were viewed, and all were found to contain an Individual Placement Agreement, and the assessment of care needs carried out by the Care Management Team, which forms the contractual arrangement and outlines the terms and conditions of stay. The information received from the Registered Manager before the site visit sated that prospective residents receive the information packs, in suitable formats or translation. A resident on a trial stay, visited the home with family before agreeing to move to Kirby House, confirmed this. The records of three residents residing at the home, all were found to contain a comprehensive assessment undertaken by a Social Worker. The assessment of needs identified the residents care needs, history such as medication, mobility, special diets and meals, communication needs, mental wellbeing cognitive impairment and social, religious and cultural needs. The admission process is good and involves the prospective resident and now, their relative or advocate. There were no residents using the intermediate care facilities – Community Reablement Service. The information received before the site visit and discussion with the Registered Manager stated that the information packs about the service could be provided to social workers to share with the prospective residents and their relatives. Kirby House DS0000032927.V339919.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are well cared for having their tailored health and daily care needs met through personalised care. EVIDENCE: The care plans and records of three residents read were well written and were presented to a good standard and have significantly improved, to guide staff providing the care. Kirby House has improved the care plans by using a ‘person centred’ approach, focusing on the holistic needs and lifestyle of the resident, and give clear direction to staff that provide assistance to meet their care needs. Residents were aware of their care plans and said they were consulted. The risk assessment completed and where safety measures identified in relation to equipment, these were listed in the care plan. The residents’ preference of daily living was recorded and any known impact of cognitive impairment due to their disability or dementia was well documented. Specific Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 12 health care support provided by the General Practitioner and District Nurse was included in the care plan. There was evidence of both the resident and their families being involved in the care planning process, where history and background of the resident, lifestyle, observance of religious or spiritual practice and social interests and their last wishes reflected a whole person. This demonstrated that the Registered Manager and staff have actively encouraged family to be involved in care planning. Residents said they felt their care and health needs were met timely and in a manner that suited them. The records showed residents having access to the General Practitioner and District Nurse, when required. A resident sat waiting for the District Nurse, said the District Nurse changes the dressing on her leg regularly in private during her short stay at Kirby House. Throughout site visit, staff were observed speaking with residents in a sensitive manner, addressing them by their preferred names whilst promoting of their privacy and dignity. A resident requiring greater assistance from staff, described how staff specifically, the key-worker provides support, promotes privacy and dignity, which helps with their self-esteem. Residents were seen moving around the home freely. Comments received from the survey and directly from the residents showed residents’ privacy and dignity was respected, and encouraged to maintain as much independence as possible. Staff were observed throughout the site visit, interacting with residents and responding to call bells, which rang occasionally. Residents were observed being assisted to the toilet or to their bedrooms when asked. Staff were observed using equipment safely, when transferring residents. Residents were observed receiving their medication at lunchtime and said they receive they medication on time. A trained staff was observed administering medication to residents individually. The medication and medication records with a photograph of the resident were viewed for some residents; all were found to be in good order. Arrangements are in place and safe storage is provided for residents’ that self-medicate. The staff training records also confirmed that the member of staff administering the medication had received training in safe handling and administration of medication. Comments received from the survey and directly are incorporated: “Carers cover me up” “Always ask me and waits for me to reply” “I get my say and have things done how I like it” Kirby House DS0000032927.V339919.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents continue to make choices about daily living; offered a variety of meals and social activities of interest to suit. EVIDENCE: Residents benefit from a flexibly run home, which enables them to make choices as to their daily lives. The care plans provides staff with information as to resident’s preferences, hobbies, including observance of religious or spiritual practice and interests, which are then incorporated into their daily social activities. Daily records showed residents received visitors, participated in activities or trips out. The Activity Organiser at Kirby House arranges activities on a daily basis. Dates of religious service are placed on the notice board although some residents receive individual Holy Communion and one resident goes to the local church. On the day of the site visit, residents and people that attend day care were seen playing Bingo in the smaller lounge. Other residents were seen sitting watching television, doing word search puzzles and talking with their Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 14 visiting friends in the conservatory and one resident returning from the day centre. One resident said they reading the daily newspaper that they receive. The library service provides books on a regular basis, some in large print. The activities folder showed the range of activities provided for the residents both at the home and trips out and residents that participated in the activities. Staff were seen helping a new resident settle into the home, and look at how they can support the resident to pursue his interests in walking and golf. There is a ‘Residents Comfort Fund’ and staff arrange social events to raise funds. Residents said they are asked about their views at the ‘Residents’ Meeting and often receive good responses. Minutes of the ‘Residents Meetings’ were read and showed how residents were involved and informed about any proposed changed and improvements to Kirby House. Staff were observed supporting residents with their daily routines. Staff said they have specific responsibilities in relation to residents they key-work and specific duties delegated by the Registered Manager on a daily basis for the running of the home and meeting resident’s needs such as assisting resident with bathing or showering. Residents said the as a result of a recent ‘Residents Meeting’ the menu has been changed on Mondays’ whereby they have a choice of different menu ranging from Sweet & Sour Chicken to spaghetti bolognaise. Care records showed residents’ dietary needs and preferences. Staff in the kitchen said they receive information about a resident’s dietary needs and ensure meals are suitably prepared, from soft diets to diabetic meals. On the day of the site visit, majority of the residents were seen enjoying spaghetti bolognaise with garlic bread, served at the dining tables. Some residents preferred to eat their meals in their rooms. All the residents were complimentary about the meals served and were confident to report any concerns or dissatisfaction. Comments received directly from the residents and comments incorporated in the surveys: • • • • • • • “Enjoy doing the word search puzzles, passes the time of day” “Makes a nice change having spaghetti bolognaise” “Sometimes unable to put TV on straight away, if seeing to another service user” “Would like malt loaf” “There is a varied menu” “I have some meals that can be microwave when the meals are not to my liking” “Visit to the pub” Kirby House DS0000032927.V339919.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are protected by a robust and accessible complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: Residents when asked were confident that should they have any concerns, to whom they should speak with. Residents were aware of how to make complaints and the written complaints procedure, and how to contact Advocacy Services. Comments received from residents directly and surveys included: “I would tell my daughter if I was unhappy or had a problem if staff didn’t listen to me” “No concerns about how staff conduct themselves always think of my safety and my wellbeing first” “The key worker is the person I speak to her . . . . I also tell my daughter” A visiting friend expressed concerns along with the resident to the Inspector about the stained pillowcase not being changed after being reported. The Inspector raised this with the member of staff present and the Registered Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 16 Manager. After lunch, the resident told the Inspector that the pillowcase had been changed and was satisfied. Information received from the Registered Manager before the site visit stated Kirby House received 5 complaints. Records showed the concerns related to the laundry arrangements and attitude of staff, all were addressed promptly and to the satisfaction of the complainant. In addition, the laundry room has improved by creating ‘wet and dry’ areas in the laundry room, allowing for safe storage of residents laundry. The Commission for Social Care Inspection has not received any expressions of concern about Kirby House. Staff demonstrated a good understanding of their responsibility and procedures to follow in relation to safeguarding adults and was confident to whistle blow on poor or bad care practices. Staff files examined contained evidence to show that staff have received training in safe guarding adults, part of the local authority induction training and attaining a National Vocational Qualification (NVQ) in Care. Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are provided with a warm, safe, clean, comfortable and wellmaintained environment suitable for their needs. EVIDENCE: Residents spoke positively about the home environment. Communal areas were decorated to a high standard, bright and well ventilated. Communal areas including lounges, dining areas and corridors were clean and tidy. Residents have a choice of lounges on the ground and first floor, including a designated smoking lounge that was being used by a resident. The bedrooms are located on the ground first floor and access using the passenger lift of stairs at the centre of the building. Bath/shower rooms and toilets are close to the bedrooms and equipped, protective clothing, hoists and Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 18 grab rails. Equipment is available to assist residents and staff in providing personal care, such as assisted baths, hoists and shower chairs. Residents were observed moving around the home, without restrictions. The Inspector was invited by residents to see their bedrooms and said they were offered keys to their bedrooms. Two bedrooms viewed were decorated and furnished to a good standard, with lockable storage and personalised. A resident said they were happy with their bedroom, which was spacious, close to the toilet and bathroom and equipped with a ceiling track hoist and low level light switches, which suited their needs. The information received from the Registered Manager before the site visit stated that four bedrooms have been fully decorated and furnished, dining room and lounge have been decorated, the laundry room was renovated and improvements made to the bathing facilities and the gardens. The information received confirmed Kirby House has a policy in place for preventing infection and managing infection control. Staff were observed wearing protective clothing when assisting residents with their personal care needs or handling food. Staff said that they had received training in infection control, demonstrated a good understanding and practice in health, safety, hygiene and infection control, which was consistent with the staff training records. There is a team of domestic staff responsible for the cleanliness of the home and the laundry. The monthly visits carried out by a representative of the local authority looks at the home environment and reported areas of concerns and safety are addressed. Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are protected by robust recruitment processes and trained staff to ensure the care needs are met timely and safely. EVIDENCE: Kirby House generally employs sufficient staff to meet the needs of residents and are in the process of recruiting new care staff to cover pending maternity leave. Staff were seen reading the ‘delegated tasks’ book, that gave clear instructions as to staff’s roles and responsibilities during that day. Observations made during the site visit indicated that whilst they were short of a member of staff during the morning, residents’ needs were being met. The recruitment and selection procedure in place is robust and is supported by a Human Resource Team in accordance with the local authority equal opportunity policy and guidance. The files of three staff were viewed and all files contained thorough pre-employment checks including Criminal Record Bureau disclosure and protection of vulnerable adult check, a completed application form and two written references. The information submitted to CSCI by the Registered Manager before the site visit, detailed the training provided and planned for staff, which included Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 20 infection control, medication training, moving and handling, food hygiene and first aid. Training records viewed, highlighted a variety of topics, pertaining to the health and safety of residents and staff. A number of staff have had training in the care for people with dementia. The staff training matrix showed the skill mix of staff, having female and male carers, to be able to provide care and support to the residents currently living at the home. The Registered Manager confirmed over 50 of the staff had attained National Vocational Qualification (NVQ) in Care, level 2 or above with a further 18 of staff undertaking NVQ 2 and above. Staff were aware of their roles and responsibilities, where to find the home’s procedures and who to report any concerns to. Staff said they felt supported by the Senior Officers and the Registered Manager. Staff said that they have handover meetings at the change of shift and staff meetings on a regular basis. The minutes of the meetings available and demonstrated staff are informed. Residents said they felt that the staff understood their needs. Staff were seen responding to residents promptly and assisting residents walking with the residents and generally having a good rapport with the residents, encouraging the resident to do as much as possible, safely. Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well managed home with good leadership, having opportunity to shape and improve the service, whilst ensuring their health; safety and welfare are promoted. EVIDENCE: The Registered Manager underwent the CSCI fit person process to be the Registered Manager for Kirby House. The Registered Manager has a number of years experience working and managing a residential care home. The information received from the Registered Manager before the site visit stated she has attained the Registered Managers Awards, National Vocational Qualification, level 4 and is a qualified NVQ Assessor. Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 22 A representative of the management team of the Local Authority, who is external to Kirby House, visits the home on a monthly basis, representing the Responsible Individual. The reports generated from each visit, demonstrated checks are carried out monthly, detailed the evidence, the findings and the actions required to address any issues. Residents were confident in the management team, and said they were able to discuss with them, any issues about the provision of care individually. Residents meetings are held regularly and the minutes of the meetings are displayed on the notice board. Kirby House actively takes forward suggestions made by the residents to improve their quality of life and the home. Residents, relatives and professionals such as the General Practitioners, District Nurses and reports from the Fire Officer, Environmental Health and Pharmacist have contributed in the quality assurance process. The results of the findings were published in September 2006 and shared with the residents, at the Residents Meeting. This demonstrated that Kirby House has systems in place to self-regulate and quality monitor the provision of care provided, through the views and opinions of the residents and their relatives. A number of ‘thank you’ cards, letters and commendations were on site, complimenting Kirby House and the staff for the care residents received. Residents said they manage their finances themselves or with support from their family or Solicitors. Where small amount of money is held on behalf of the resident, a record of the financial reconciliation is in place, which demonstrated procedures are in place for handling residents’ finances. Residents and staff records viewed were kept in good order, comprehensive, up to date, stored securely and was available for the purpose of the site visit. Staff were aware of where information, incident and accident record, policies, and procedures are kept. Assessments of risk for falls, moving and handling are carried out, and safety measures reflected in the care plans. Staff said they receive supervision and attend staff meetings and records supported this. The information received from the Registered Manager before the site visit indicated equipment such as hoist, lift fire detection and emergency equipment, is maintained. Kirby House has a planned programme of maintenance. The Registered Manager said risk assessments are in place for the home, residents and an emergency plan. A sample of fire drill and test records, water temperatures checked were consistent with the information received. The accident/incidents records viewed were consistent with those received by the Commission. Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 23 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 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 4 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 3 17 X 18 3 3 3 3 3 3 3 3 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 3 3 Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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. Refer to Standard Good Practice Recommendations Kirby House DS0000032927.V339919.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Leicester Area Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V339919.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!