Inspection on 31/05/05 for Kirby House

This inspection was carried out on 31st May 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 22/08/05

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 31 May 2005, 10:00am st 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 S32927 Kirby House V229978 020605.doc Version 1.30 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 S32927 Kirby House V229978 020605.doc Version 1.30 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 21st January 2005 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 specdialist 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. Residential Home is a purpose built home owned by Leicestershire County Council. Kirby House is fully accessible, the 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 C51 S32927 Kirby House V229978 020605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection took place between 10.00am and 2.30pm. Opportunity was taken to look around the home, view records and policies which included viewing the care plans of four individuals residing at the home, time was also taken to talk to residents and staff including the Deputy Manager. What the service does well: What has improved since the last inspection? What they could do better: Residents would benefit from a comprehensive daily record being completed by care staff, which reflects there identified needs and incorporates daily social activities. This recorded information would provide information, which would support staff in the reviewing of residents in both long term and respite care and those accessing the rehabilitation unit. Individuals accessing the day care are currently not consulted about aspects of the service they receive, questionnaires or meetings could be organised, facilitated by the Activities Organiser in order that their views are incorporated into developing the service. Kirby House C51 S32927 Kirby House V229978 020605.doc Version 1.30 Page 6 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 S32927 Kirby House V229978 020605.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 Kirby House C51 S32927 Kirby House V229978 020605.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, 4, 5 and 6 The admission process is well managed with residents and their individual needs being assessed; thus ensuring staff have the appropriate information to meet individual needs. EVIDENCE: There is a guide to services at Kirby House for residents accessing long term care, with additional information being provided for those individuals accessing the rehabilitation unit. Care plans viewed contained the assessment undertaken by the Social Worker prior to admission, and for those individuals accessing the rehabilitation unit additional assessments are undertaken by Occupational Therapists. Those individuals currently residing within the rehabilitation unit, have all met their agreed targets, and are waiting a date to return home. Kirby House C51 S32927 Kirby House V229978 020605.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 and 10. Residents are looked after well in respect of their health and personal care needs and are involved in the drawing up of their care plans. EVIDENCE: Care plans for residents accessing long term care at Kirby House, encompassed information on their health care needs, and contact with healthcare professionals was documented. Daily records could further be developed to encompass comments on individual care plans and record information as to social activities in which residents participate. Records would then reflect a holistic approach to care based on an individuals social and personal care needs and would provide an accurate record for the reviewing of resident’s needs and well being. Care plans for those individuals accessing the respite facility, need to be further developed to give a comprehensive guide to individual needs. Care plans for those individuals accessing the rehabilitation unit, were comprehensive, and had been written to incorporate the assessment undertaken by the Occupational Therapist. Daily records however did not reflect day-to-day information as to the meeting of individual targets. Kirby House C51 S32927 Kirby House V229978 020605.doc Version 1.30 Page 10 Medication policies and procedures are good; medication and administration records were viewed for a random number of residents and found to be in good order. Observation during the Inspection showed that staff have a good awareness of how to protect residents’ privacy and dignity. Staff were seen to knock on doors before entering, and sought the approval of residents before entering their room. Residents who spoke to the Inspecting Officer stated they were well cared for and were happy at Kirby House. “It’s very nice here, we’re looked after very well.” “It’s lovely here, but it’s not the same as being home.” “Staff here are very nice and helpful.” Kirby House C51 S32927 Kirby House V229978 020605.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 and 15. Residents experience a homely life style and visitors are encouraged to visit. Various formal and informal activities are made available meeting residents’ recreational needs. 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. “We can play drafts, do jigsaws and other board games.” “It would be nice to have more chairs provided with arms, to assist us in getting in and out of the chairs.” Individuals accessing the day care are currently not consulted about aspects of the service they receive, questionnaires or meetings could be organised, facilitated by the Activities Organiser in order that their views are incorporated into developing the service. Kirby House C51 S32927 Kirby House V229978 020605.doc Version 1.30 Page 12 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 a diabetic option was available. Staff were observed offering residents a choice at lunchtime, and assisted those requiring support in a sensitive manner. Kirby House C51 S32927 Kirby House V229978 020605.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) These standards were not inspected on this occasion. EVIDENCE: Kirby House C51 S32927 Kirby House V229978 020605.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 and 26. A comfortable and safe standard of accommodation is provided for the residents however some areas within the home require decoration. Residents have access to a garden with seating provided. EVIDENCE: Kirby House was refurbished several years ago, and a majority of communal areas now require decoration and maintenance. In view of this Leicestershire County Council, need to consider a programme of re-decoration for the home. The Inspecting Officer has identified some communal areas for initial decoration. The bedrooms of four residents were viewed; one bedroom had a strong odour whilst one bedroom requires decoration. The home has spacious sitting rooms on both the ground and first floor, which offers residents a variety of choices as to where to sit. The home provides sufficient lavatories and bathing/shower facilities to meet the needs of residents. Kirby House C51 S32927 Kirby House V229978 020605.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 28. Staff at the home are well trained and employed in sufficient numbers to meet the needs of residents. EVIDENCE: Staffing levels were sufficient to meet the resident’s needs at the time of the Inspection. Kirby House senior staff team consists of the Registered Manager, two part time Deputy Managers and two Assistant Managers. The Registered Manager is currently working towards his Registered Managers Award, within the Management team, there are two National Vocational Assessors. The home currently employs twenty-three care staff, of which 9 have completed National Vocational Care qualification at level 2. Training records are held for individual members of staff detailing courses that have been attended in a variety of topics including health and safety, adult protection and care practices. Kirby House C51 S32927 Kirby House V229978 020605.doc Version 1.30 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) 31. and 38 The Registered Manager offers a clear sense of leadership, which reflects on the day-to-day delivery of care practices of residents and running of the home. EVIDENCE: 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 C51 S32927 Kirby House V229978 020605.doc Version 1.30 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 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 x x x x x x 3 Kirby House C51 S32927 Kirby House V229978 020605.doc Version 1.30 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 19 Regulation 23(2) Requirement The Registered Person to ensure that the following areas of maintenance/decoration are undertaken. 1. Shower room opposite bedroom 2 to be decorated. 2. Corridor (short stay/day care) requires the wallpaper to be replaced and skirting boards and door ways painted. 3. Carpet of the day care lounge to be cleaned or replaced if stains remain. 4. Toilet opposite bedroom 11. 5. Repair to damaged wallpaper between bedroom 8 and 9. 6. Shower room requires repair to the area by the toilet on the first floor. 7. Toilet opposite bedroom 22 requires repair to the wall above the sink. 8. Bedroom 2 carpet to be cleaned or replaced should the odour remain. 9. Bedroom 6 require decoration. Timescale for action 30th August 2005 Kirby House C51 S32927 Kirby House V229978 020605.doc Version 1.30 Page 19 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 OP7 Good Practice Recommendations It is recommended that daily records comment on individual care plans and include residents involvement in social activities. The detailed information could then be used for the evaluation of care plans and health care needs. The Registered Person to set up a consultation process for those individuals accessing the day care facility, in order that their views be considered in the developing of the service. Leicestershire County Council to put together a programme for the redecoration of Kirby House, prioritorising areas of work. 2. OP14 3. OP19 Kirby House C51 S32927 Kirby House V229978 020605.doc Version 1.30 Page 20 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. Extracts may not be used or reproduced without the express permission of CSCI Kirby House C51 S32927 Kirby House V229978 020605.doc Version 1.30 Page 21 - 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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