Inspection on 12/03/07 for Kirby House Mental Nursing Home

This inspection was carried out on 12th March 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kirby House Mental Nursing Home 20/06/08

Kirby House Mental Nursing Home 20/12/07

Kirby House Mental Nursing Home 21/12/05

Kirby House Mental Nursing Home 05/08/05

Kirby House Mental Nursing Home 11/03/05

Kirby House Mental Nursing Home 25/11/04

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

CARE HOMES FOR OLDER PEOPLE Kirby House Mental Nursing Home 135 West Street Dunstable Bedfordshire LU6 5SG Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 12th March 2007 12:45 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 Mental Nursing Home DS0000017677.V331051.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 Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirby House Mental Nursing Home Address 135 West Street Dunstable Bedfordshire LU6 5SG 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) 01582 662609 01582 476945 Southern Cross Care Homes Limited Care Home 7 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (7) of places Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user can be placed in the home under the age of 65 years. 21st December 2005 Date of last inspection Brief Description of the Service: Kirby House is a small Mental Health Nursing home situated in a residential area near Dunstable town centre in the county of Bedfordshire. The home is an extended family type house with places for up to six adults with mental health care needs. There is communal dining and sitting room and a small garden area to the front and side of the property. There is a small parking area to the rear and there are good public transport links and a range of local amenities within walking distance of the home. Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 12/03/07 over 3 ½ hours by Pursotamraj Hirekar. The manager coordinated the inspection through out. The method of inspection included study of care plans, risk assessments, personnel records, staff deployment duty rota, relevant care delivery documents, discussions with manager and staff, conversation with service users’ and partial tour of the building. This inspection report also includes information from the service users’ survey carried out by the commission. What the service does well: What has improved since the last inspection? What they could do better: The home must make suitable adaptations and provide such support, equipment and facilities, including passenger lift, as may be required are provided, for service users who are old and infirm. The home must after consultation with the environmental health authority, make suitable arrangements for relocating laundry for maintaining satisfactory standards of hygiene in the care home. The home must review night shift staffing levels and deploy adequate staffs to meet the changing needs of the service users’. The home must make suitable arrangement for the location of the laundry in a manner, which respects the privacy and dignity of the service users. The registered person must ensure that the damp in the down stairs bathroom and in the down stairs wall near the bedroom is attended to. (Previous time scale 30/04/06) Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 6 The home should ensure compliance with relevant legislations including health and safety at work. 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 Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements for the assessment of needs of the service users’. EVIDENCE: The home had used a comprehensive tool for needs assessment of the service users’. The assessed needs were well documented in an easy to read format. The assessment covered information about physical and social assessment, personal belongings, funeral arrangements, pressure risk assessment, dependency assessment, continence assessment, nutritional assessment, malnutrition universal assessment, moving and handling, aggression, epileptic, when outside the home and falls. On this inspection 2 service users’ needs assessment was seen. I service user’s assessment recorded that the service user had falls - high risk. The manager had confirmed on this inspection that the service user had 2 falls in the past year. The bedroom of the service user is Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 9 on the first floor. The staircase leading to the ground floor for lounge and dinning is steep and a normal person can walk side ways as the pitch between the stairs is to low as well. The home had no other means other than this steep stairs for the service users and staffs. The manager said she is bit worried about the stairs for the service users’. The home did not undertake referrals of service users’ solely for intermediate care, but provided long-term support. The commission had undertaken service users’ survey prior to this inspection, to get the feedback from the service users’ and their family members about the care and services they get from the home. A pre-inspection questionnaire was also used for the responsible individual/manager to provide information to the commission with regard to various aspects of care provision and delivery they undertake. 5 service users’ have responded to the service users’ survey undertaken by the commission, of which 4 service users have said that they had prior information about the home, before they moved in and had signed the contract of services. Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangement s for the delivery and care of the personal and health care needs of the service users’ and the service users’ have expressed their satisfaction about the same. However, the location of the laundry is a cause of concern. EVIDENCE: On this inspection 2 service users’ care plans were seen. The care plans were comprehensive and have covered aspects of needs assessment and risk assessments as mentioned in this report under choice of home outcome group. Service user –1 care plan covered information about epileptic, blood pressure, obesity, cholesterol, mental disorder, personal hygiene, personal monies, social activities, contacts, incontinence, medication, body & facial, night routine, and inertia. Service user – 2 care plan covered delusions, bathing, personal hygiene, mobility, hypertensive, depot injection, and falling. All these areas were evaluate monthly and changes incorporated to the care plan. Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 11 The home had carried out service users’ risk assessment and care plan monthly reviews as scheduled. On this inspection 2 services users’ care review documents were seen and found that the reviews had covered all the relevant areas of care delivery and the care plans were updated accordingly. The home had maintained professionals’ visits record, service users’ personal hygiene record, weight record chart, TPR & BP observation record, visiting doctors record, and service users’ daily information record. 2 service users’ occupied one of the first floor bedrooms; their beds were separated with a curtain, and their bedroom had an attached common laundry that was in use for all the service users’. To access the laundry the staffs have to go through this double bedroom, as there was no other access point to the laundry. The location of the laundry is a cause of concern as it may spread infection and every time the laundry was accessed, the staffs have to go through the double bedroom disturbing the privacy and dignity of the service users’. The home must review the location of the laundry and make suitable arrangements to help achieve quality of life goals of the 2 service users’ using the double bedroom. Of the total 5 service users’ 4 service users have said that they always receive the care and support they need and 1 service user said they receive usually. However, when asked do they receive medical support they need, 4 service users’ said they received medical support always. Service user – 1 said ‘I always receive satisfactory care and support’. ‘Service user – 2 said ‘I risk living here’. Service user – 3 said ‘I now receive the support I need under the new manageress’. Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ dietary needs were assessed and choice of menu and timings were maintained, in the interest of the service users’. The service users’ were satisfied with the social activities carried out by the home. EVIDENCE: The home had developed a framework for activity programme of service users’ and the service users’ had wide range of activities that were spread across the week, which included; topical discussion, scrabble, dominoes, snakes and ladders, community meeting, befriend club, market shopping, library, eating out and minibus outing. The home had facilitated appropriate communications among the family members, friends, and service users’. Of the 5 service users’ who responded to the commission’s survey, of which all the 5 service users said they always participate in the activities. Service user – 1 said ‘Like dominoes’. Service user – 2 said ‘I play scrabble, dominos and bingo’. Service user – 3 said ‘I spent most of my time reading or watching my TV, do take part in games usually particularly scrabble’. Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 13 The food menu was prepared in consultations with the service users and each and every service users dietary needs were taken into account. The kitchen was clean and neat. Of the 5 service users’ who responded to the commission’s survey, of which all the 5 service users’ have said to the survey that they always like the meals at the home. Service user – 1 said ‘lovely food’. Service user – 2 said ‘The meals are fantastic but could we have some fruit provided for us’. Service user – 3 said ‘I enjoy them’. Service user – 4 said ‘Since we have had new cook the meals are excellent’. Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ were aware of the complaints procedure and were confident to use the same when necessary. EVIDENCE: The home had a comprehensive complaints policy and procedures in place. All the service users’ and visitors had access to the displayed complaints procedure. The staff had been given training in POVA. Of the 5 service users who responded to the commission’s survey, of which 4 service users’ have said that they always speak to if they were not happy with any of the service at the home and also were aware how to make a complaint. Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 15 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, 22, 24 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home was maintained clean and tidy and the service users’ were happy about it. However, the location of laundry and steep staircase is a cause of concern for the well being of the service users’. EVIDENCE: The home was maintained clean and tidy without any offensive odour. Currently, the home had 6 service users’ of which 2 service users’ were on the ground floor and 4 service users’ were on the first floor. The 4 service users’ on the first floor use the only staircase to reach the dinning and the lounge on the ground floor. The staircase is very steep and even a normal person need to walk sideways as the pitch between the stairs is low as well. 1 service user had 2 falls in the past year, and cannot walk on her own to the dinning and lounge Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 16 on the ground floor with out the help of staff. She is in her room most of the time. The home must carry out an occupational therapist audit of the premises in relation to the changing needs of the service users’ and implement recommendations. 2 service users’ occupied one of the first floor bedrooms; their beds were separated with a curtain, and their bedroom had an attached common laundry that was in use for all the service users’. To access the laundry the staffs have to go through this double bedroom, as there was no other access point to the laundry. The location of the laundry is a cause of concern as it may spread infection and every time the laundry was accessed, the staffs have to go through the double bedroom disturbing the privacy and dignity of the service users’. The home must review the location of the laundry and make suitable arrangements to help achieve quality of life goals of the 2 service users’ using the double bedroom. The remedial work was done to the dampness downstairs. However, the problem reoccurred and the contractor was scheduled to attend to the dampness this summer. The home was in the process of installing a new bath on the ground floor and the need for procurement of garden furniture was being discussed at the management level of the home. All the 5 service users’ those who have responded to the service users’ survey have said that the home is always fresh and clean. Service user – 1 said ‘Excellent’. Service user – 2 said ‘My friends comment on the cleanliness of the home’. Service user – 3 said ‘Very clean nursing home’. Kirby House Mental Nursing Home DS0000017677.V331051.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s policy on staff recruitment was comprehensive. The home need to improve staff deployment for the night shift to meet the changing needs of the service users’. EVIDENCE: The home had been operating on a 3-shift system. The night shift had only 1 staff on duty and the other 2 shifts had 2 staffs working. Considering the changing needs of the service users’ and the bedrooms were on the ground as well as first floor, the home must review staffing levels for the night shift and increase staff deployment to meet the changing needs of the service users’. On this inspection 2 staffs records were seen and found the recruitment procedure was appropriate. The home had provided a detailed staff training matrix, which indicated that the home had carried out staffs’ mandatory training that included; manual handling, protection of vulnerable adults, health and safety, administration of medication, dementia, fire, first aid, COSHH, must and continence. All the 5 service users’ those who have responded to the commissions’ survey have said that the staff listen and act to what the service users’ say and are Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 18 always available when they need them. Service user – 1 said ‘the staff are very attentive at all times’. Service user – 2 said ‘There are staff on duty 24 hours a day’. Service user – 3 said ‘The staff are always available on the home when you need them’. Kirby House Mental Nursing Home DS0000017677.V331051.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home manager had good working relations with the service users’ and their family members, staffs and relevant professionals. The home manager must improve the conditions of the premises to help achieve the quality of life goals of the service users’. EVIDENCE: The home had a new manager who said that she was spending 33 hours on work with service users’ and 7 hours on management tasks. The manager of the home had good working relations with the staffs’ service users’ and their family members, and relevant professionals. The staffs’ and the service users’ spoken to, all have appreciated the way the home was run by the manager. Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 20 Service users’ finances were not seen on this inspection. The assessed healthcare and personal needs of the service users’ were met with adequate standards as reported under various outcome groups of this report. However, there were concerns regarding the staircase and location of the laundry room, which do not help achieve the quality of life goals of service users’. Audits are done monthly and reports are sent to the head office regarding medicine and home audits, pressure sores and incident/accident reports, training matrix, service users 6 monthly reports. The manager had said that the work on annual development plan was in progress and was likely to be concluded by the end of April 2007. The staffs’ supervision was carried out regularly that helped both the staffs as well as service users’. What the Service users’ and their family members have said to the service users’ survey carried out by the commission are as follows: Service user – 1 said ‘I wish to stay at Kirby house for ever’ Service user – 2 said ‘I risk living here’ Service user – 3 said ‘I am satisfied in Kirby house’ Service user – 4 said ‘On the whole this is a very good home, you get very good care’ Kirby House Mental Nursing Home DS0000017677.V331051.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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 1 11 X 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 1 X X 1 X 1 X 3 STAFFING Standard No Score 27 2 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 2 Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP24 Regulation 23 (2) (n) Requirement Timescale for action 31/05/07 2. OP22 16 (2) (j) 3. OP27 18 (1) (a) 4. OP10 12 (4) (a) The home must make suitable adaptations and provide such support, equipment and facilities, including passenger lift, as may be required are provided, for service users who are old and infirm. The home must after 31/05/07 consultation with the environmental health authority, make suitable arrangements for relocating laundry for maintaining satisfactory standards of hygiene in the care home. The home must review night 30/04/07 shift staffing levels and deploy adequate staffs to meet the changing needs of the service users’. The home must make suitable 31/05/07 arrangement for the location of the laundry in a manner, which respects the privacy and dignity of the service users. The registered person must ensure that the damp in the down stairs bathroom and in the DS0000017677.V331051.R01.S.doc 5. OP19 23 30/04/07 Kirby House Mental Nursing Home Version 5.2 Page 23 down stairs wall near the bedroom is attended to. (Previous time scale 30/04/06) 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 OP38 Good Practice Recommendations The home should ensure compliance with relevant legislations including health and safety at work. Kirby House Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Mental Nursing Home DS0000017677.V331051.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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