Inspection on 20/12/07 for Kirby House Mental Nursing Home

This inspection was carried out on 20th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 12/03/07

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 1SG Lead Inspector Ansuya Chudasama Key Unannounced Inspection 20th December 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kirby House Mental Nursing Home DS0000017677.V356863.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.V356863.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 1SG 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 kirbyhouse@schealthcare.co.uk Southern Cross Care Homes Limited Ms Neo Loate 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.V356863.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. 12th March 2007 Date of last inspection Brief Description of the Service: Kirby House is a small 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.V356863.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector undertook an unannounced inspection visit on the 20 of December 07 The inspector spoke to the manager and staff who were on duty. She talked to the people using the service, and asked staff about those people’s needs. She also looked at the medical records and daily notes for one of the people living in the home. This is called case tracking. A partial tour of the home was also undertaken. Staff recruitment records, and the previous requirements and recommendations were also checked to find out if the action had been progresses within the time scales. At the time of the inspection there were six people living in the home. The home had no vacancies at the time of the visit. An immediate requirement was issued on the day of the inspection to the organisation. This was because the central heating in the home has not been working since June 07. The people using the service spoken to had complained that the heating had not been working and they felt cold when walking through the corridors, dining room, lounge and using the bathroom and toilet. It was stated that the staff had been feeling cold too. The organisation was required to inform the CSCI of the contingency plans being put in place to ensure that the people living in the home are kept warm and safe. And when they were going to get the central heating system working. An action plan to meet the immediate requirement made was received by the operations manager of the home on the 21/12/07. The inspector would like to thank the manager, staff, and the people living in the home for their time in helping with this inspection. This inspection report should be read alongside the National Minimum Standards for Older People. What the service does well: Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 6 The lounge looked very festive and homely. The people using the service were getting ready for Christmas. They described the home as being ‘one big family home’. The people in the home like living at the home. They feel well cared for by staff and say that they treat them well. They say their privacy is respected. They like the food and activities they do with help from staff. They also know who to tell if they are not happy. The manager and staff enjoy working at the home. The staff and the people living in the home were observed interacting and talking to the people living in the home in a positive and caring manner. What has improved since the last inspection? What they could do better: The home should ensure that: The boiler is repaired. Effective quality assurance and monitoring systems are put in place The bathroom and the toilet on the ground floor are redecorated and the damp in the bathroom is attended to. Provide the manager with more formal supervision that is recorded. Undertake risk assessment to ensure the people living in the home are safeguarded from any harm. Make a referral to the occupational therapist to undertake an assessment of the premises. Ensure that the controlled drugs are kept secure in a metal cupboard Ensure that the medication records are signed at all times Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 7 Inform the CSCI or social services in writing of any event in the home that adversely affects the well being or safety of any service users 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.V356863.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 Mental Nursing Home DS0000017677.V356863.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): 1,2,3,4,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people using the service had been provided with information and had visited the home prior to making a decision to live there. EVIDENCE: The home had not admitted any new people since it was opened in 1990. The people spoken to stated that they had all visited the home with their families, and the funding authorities before they made a decision to stay. The needs of the people living in the home were also assessed by the home before they moved into the home. The service user guide needs to have the information about the laundry room being accessed through a ‘service users’ bedroom. The information on what it cost to stay at the home also needs to be recorded in the document. Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 10 The home did not provide intermediate care service. The people spoken to stated that their families signed the contract and they were responsible for this. The staff in the home had the training and experience of meeting the needs of the people that they cared for. Kirby House Mental Nursing Home DS0000017677.V356863.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): 7,8,9,10,11. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home understands the need to comply with the administration, safekeeping, and disposal of controlled drugs, and to follow practice guidelines to meet the needs of the people using the service EVIDENCE: All the people living in the home had care plans. One persons care plan was looked at in detail. Evidence showed that this plan was being reviewed and updated on a monthly basis by the manager. The care plan covered detailed information on how the health care, medication, social needs and personal care needs were being met. The staff had very good understanding of the needs of the people living at the home. Qualified nurses only gave out medication in the home. The medication cupboard was kept in the lounge cupboard. The cupboard did not have a light Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 12 and the staff has to rely on using the light from the lounge when giving out medication. This light was not very bright. The organisation should consider putting a light in the cupboard to avoid any accidents happening when giving out medication. The medication record sheets needs to be signed at all times by staff when giving out medication. The home had controlled drugs but these were not kept in a metal cupboard as stated in the policy. The temperature of the medication was being undertaken. The manager stated that she got Boots pharmacist to do a medication audit which’ was done on the 28/11/07 and it was stated that they would provide the home with a metal cupboard in the first week of January 2008. The manager stated that the staff were given a training video on medication and 4 nurses were having refresher training on medication in the first week of January 08. The home was getting a thermometer, which met the regulation in December 07. The one that the home was using was not the right one. There was also information about the social activities being undertaken in the home by the person. The daily records read showed that health professionals were visited when required and information was being recorded well. Reviews by the funding authorities were being carried out on a yearly basis and families and the person living in the home being discussed were being involved in these meetings. Information on burial wishes was recorded on the files for the people living in the home. Kirby House Mental Nursing Home DS0000017677.V356863.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): 12,13,14,15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people living in the home are provided with healthy cooked meals to ensure that their dietary needs are met. EVIDENCE: The inspector was informed that some of the people in the home helped out with washing up the cutlery in the mornings. Some helped with laying and clearing up things from the table. All the people living in the home spoken to stated that they wanted to stay together as they were a family. The home had 20 hours activity hours per week. The staff in the home provided these activities. The variety of activities included playing scrabble, cards, music, bingo, and dominoes. One person attended day care three times a week. One person in the home needs one to one with staff when going out in the community. Two people in the home are able to go out on their own Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 14 and two other people in the home need staff supervision when going out in the community. It was stated that all except two people in the home went out for a Christmas meal and enjoyed this. All the people living in the home described the food as being tasty and some stated it was very nice whilst others stated it was excellent. It was also stated that it was fresh home cooked and they could not fault it. The people living in the home were observed eating their tea and evidence showed that this was eaten in a relaxed atmosphere. The staff were observed helping in a kind manner. The home had very good understanding about what food the people in the home enjoyed. They were also informed about each day about the meals that were being prepared. Discussion with the manager about getting the people in the home to choose the menus by using pictures was discussed and the manager was going to look into this. She was also going to look into having jugs of water or juice put on the table at meal times so the people in the home that were able to help themselves would be able to do this by themselves, and those who needed help would be helped by staff. The home had good relationships with families and friends of the people living at the home. It was stated that some families visited more often than others. One person stated that her family visited them and knows that they are well looked after and this was a good home. Kirby House Mental Nursing Home DS0000017677.V356863.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): 16,18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The accident and incident forms were being completed well by the home, however some incidents were not being reported to the CSCI and social services due to a lack of understanding of when incidents should be reported under regulation 37 of the National Minimum Standards and safe guarding procedures. EVIDENCE: The home had a complaints policy, which was displayed in the dining room. The home had not received any complaints since the last inspection. The people living in the home knew who to speak to if they were not happy and knew how to make a complaint. The staff spoken to and those staff training records looked at showed that they had received training on safeguarding of vulnerable adults. The staff had very good understanding of the needs and behaviours displayed by the people living in the home when they were either feeling unhappy or unwell. The accident and incident records seen showed that one person in the home had unexplained bruises that the person and staff were not able to explain how this had happened. Under regulation 37, notification of death, illness and other events, the home had not reported this incident to the CSCI or to social Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 16 services under SOVA. The incidents of any falls happening in the home needs to be reported to the CSCI. The finances checked for one of the people living in the home was correct. The manager explained how the person’s money was managed and this was recorded. Kirby House Mental Nursing Home DS0000017677.V356863.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): 19,26 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The manager had good understanding of the areas of the environment that needed improving to meet the needs of the people living in the home however the lack of action by the providers in relation to the central heating has had a detrimental impact on the quality of people’s lives. EVIDENCE: (See section on management regarding the home not having any heating since June 07). The people living in the home stated that they had one heater keeping the lounge and dining room warm. One person in the home said that they tried to keep the conservatory door shut to try and keep the lounge Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 18 warm. This was observed on the day of the inspection. It was stated that it was not very warm in the communal areas and having a bath in the mornings was freezing. The weather had also recently been very cold and it was very cold on the day of the inspection. One of the people living in the home stated that it was ‘not fair that we should live like this’. Evidence showed that the manager had sent quotes of repairing the boiler to the organisation but no action had been undertaken by them to repair or replace the boiler. One of the bedrooms inspected of a person living in the home smelled strongly of urine. This was discussed with the manager who stated that the person had an accident. However the manager needs to finds ways of eliminating the strong smell to make it pleasant for the person using the room. The rest of the home was clean and odour free. It was stated that the bathroom and toilet downstairs had been painted. However evidence showed that the paint was peeling off and there was damp and mould at the corner of the bathroom. The toilet down stairs also needed decorating because the paint was peeling off. At the last inspection it was stated that the home was in the process of installing a new bath on the ground floor. The manager stated that this did not happen, as the space did not meet the specification of the new special bath. It was stated that an ordinary bath would have to be installed. The home needs new curtains and matching bed linen for some of the people living in the home. The conservatory had curtains, which were short in areas and did not look pleasant. Consideration should be given to having blinds to provide the staff and the people living in the home privacy at nighttime. One person living on the ground floor was observed having difficulty opening the door to come into the lounge area. The person had to wait for a member of staff to open the door to help them through to the lounge. The inspector was informed that these were fire doors and were heavy and had to be kept closed. This person was also very frail and needed one to one with staff. At the last inspected it was stated that ‘1 service user had 2 falls in the past year, and cannot walk on her own to the dinning and lounge 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 (OT) audit of the premises in relation to the changing needs of the service users’ and implement recommendations’. This OT assessment had not taken place. The manager stated that she had made a referral to the GP for an occupational therapist assessment on the 12th of June 07. However she had not followed this up. On the 24th of December 07 the manager stated that she had contacted the GP about an OT assessment of the premises. The manager needs to ensure that the two people who are now frail have an individual assessment undertaken using the premises. Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 19 The manager had got the fire safety officer to assess the home for a stair lift and a passenger lift. However it was stated that this was not possible due to the structure of the home. The home had bought second hand garden furniture and the garden was improved. This was not inspected on this occasion. It was stated at the last inspection that to ‘access the laundry the staff have to go through a bedroom of two people using the service. It was felt that the location of the laundry is a cause of concern as it may spread infection and every time the laundry was accessed, the staff are disturbing the privacy and dignity of the people using the service’. Health and Safety at work officer visitor the home on the 1/6/07. The recommendation stated that the location of the laundry room poses no immediate risk to health and safety. It also stated that if the washing machine and dryer are located to the cellar, consideration must be given to the risks associated with this area. For example flooding. The manager had discussed this with her manager and it was stated that ‘there is nothing we can do’. The manager got the two people living in the home to sign a form giving consent for staff to go through their room to access the laundry room. It was stated by the manager that staff only used the laundry room during the day when the people using the room were not in their room. It was also stated that laundry was only carried in special bags when going through the bedroom. Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 20 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): 27,28,29,30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The staff are trained and competent to meet the needs of the people being cared for by the home. EVIDENCE: Two staff files were inspected. The files had information required for the protection of people living in the home. The files had certificates of training undertaken by staff. The staff confirmed that they had good training. All staff had completed training on safe working practices, and safeguarding of vulnerable adults. The three care staff had completed NVQ level 2 or 3 in care and had undertaken other training. It was stated that the manager had to work hard to get the staff the training they required. The organisation needed to be more supportive and to help make it easy for staff to access training. The home’s staff provided staff inductions. The rest of the staff in the home were qualified nurses, and the home had one cook and a housekeeper. One staff spoken to had worked at the home for a year. The staff stated that they had induction training when they first started work. They were also receiving supervision. This was confirmed when staff files were inspected. One staff stated that it was ‘lovely working at the home and they felt part of Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 21 the team. Another staff said that the atmosphere working at the home was friendly and people living in the home got on well together. The staff did also not enter their rooms unless they had their permission. Most of the staff had worked at the home for many years and one member of staff had been at the home since it first opened. The people using the service spoken to stated that the staff are “wonderful” and they have time to “listen to them”. The staffing ratio of staff to people living in the home was discussed with the manager. It was stated that at present the staffing ratio was meeting the needs of the people living in the home. This was confirmed by some of the staff spoken to at the inspection. Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 22 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): 31,33,35,36,38 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The organisation has not taken action regarding the central heating or provided suitable replacement arrangements to ensure that the lives of the people using the service are protected from any unnecessary risks to their health and safety. EVIDENCE: The manager has a qualification at level NVQ level 4 in care and she had recently completed her registered managers award in November 07. One staff spoken to stated that the manager was ‘lovely’ and ‘good at listening and understanding of problems’ and giving advice. Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 23 The 6 hours per week given to the manager to undertake her responsibilities as stated in the standard and in her job description was not adequate. Evidence showed that the manager was finding it difficult to do her registered managers duties within the 6 hours allocated for administration time and working the rest of her hours on the staff rota shift. The organisation needs to review the manager’s hours to ensure that she has the hours needed to undertake her responsibilities within her registered managers role. The manager stated that she had supervision with her line manager on a three monthly basis. However there was no evidence to show that these meetings were being recorded and signed by both parties. The organisation needs to ensure that the manager receives more than four supervisions per year. The supervision needs to be recorded and signed and dated by both parties. The home was issued an immediate requirement notice on the day of the inspection. This was because the central heating in the home was not working and the CSCI was not informed about this. Risk assessment for people using convector heaters in their rooms and those being used in the communal areas had not been undertaken. Staff informed the inspector that the organisation had asked them to cover the heaters. However it was stated that they did not undertake this task as this was not safe and it was also stated on the heaters that they were not to be covered. The people living in the home informed the inspector that they were not very warm when using the communal areas and after they had a bath. It was also stated that some of the staff had also complained of feeling cold especially at nighttimes. This was confirmed by some of the staff. The company’s procedure states that the manager of the home has to consult the organisation before they are informed to send out regulation 37 notifications. The organisation had not informed the CSCI that the central heating system was not working. Evidence showed that the home had heating problems since March 07, and since June 07 the heating has not worked. Evidence showed that the manager had quotes sent to the organisation but it was stated that they were expensive and the home was to use electric convector heaters. The manager discussed the high heating bills with her manager on the 18th of December 07. The manager was asked to get more quotes. A response was received for the immediate requirement letter on the 21/12/07 stating the action that the organisation was going to undertake. A phone call to the home was made on the 24th of December 07 by the CSCI. This was to check if the action stated from the immediate requirement was being implemented. The manager stated that convector heaters were put in the corridors and all the bedrooms. The temperatures were also being monitored on a 3 hourly basis. The manager stated that she had also completed the risk assessments for people using the service who had convector heaters in their room. The manager also stated that plans to have a new boiler would take Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 24 place in January 08 but she did not have a date for when the work was to start. Evidence showed that quotes were given to the organisation by the manger for the repair of the boiler. On the day of the inspection an engineer had come to look at the boiler and it was stated a quote was provided following this visit. The manager had completed a basic annual development plan but more information was needed with dates of when tasks were to be completed. The home carried out regulation 26 visits on a monthly basis but failed to inform the CSCI of incidents under regulation 37. The home did not have a quality assurance system that met the standard. The staff spoken to state that they had a fire drill in October 07,and the people living in the home was also involved with this process. The staff also confirmed that fire drills were being carried out on a weekly basis and they were responsible fire person for the home. The fire Officer had visited on the 16th of May 07 and had asked for a fire risk assessment. It was stated that the fire safety measures put in the premises and the outcome of the audit was considered to be satisfactory. (See section on complaints and protection regarding accident and incident forms.) The finances checked for one of the people living in the home was correct. The manager explained how the person’s money was managed and this was recorded. Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 25 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X 1 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 2 X 3 2 X 1 Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 26 Yes 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 OP19 Regulation 23 Requirement The registered person must ensure that the damp in the down stairs bathroom is attended to. (Previous time scale of 30/04/06 and 30/04/07 not met) 2. OP24 23 (2) (n) 29/02/08 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. Previous time scale of 31/5/07 not met 3 4 OP9 OP9 13 13 The registered person must ensure controlled drugs are kept secured in a metal cupboard The registered person must ensure that medication records are signed at all times to show evidence that medication has been given out to the people living in the home. DS0000017677.V356863.R01.S.doc Timescale for action 29/03/08 29/01/08 29/01/08 Kirby House Mental Nursing Home Version 5.2 Page 27 5 OP18 6 7 OP33 OP36 37 and Safe Guarding of vulnerable adults policy. 24 18 Any incidents of unexplained bruising must be reported to social services under SOVA and CSCI. 29/01/08 8 OP38 37 9 OP38 12,13 10 OP25 23 Provide a quality monitoring audit for the home that meets the standard. The registered provider must ensure that the manager receives formal supervisions that are recorded and signed by both parties and this needs to be more than 4 a year. Under regulation 37 of the Care Standards Act 2000 the registered provider must inform the Commission for Social Care Inspection in writing, of any serious injury to a service user and any event in the care home that adversely affects the well being or safety of any service user. The registered person must undertake risk assessments for using the convector heaters to ensure that the people living in the home are kept safe. The registered person must repair the central heating system to meet the needs of the people living in the home. 29/03/08 29/12/08 29/01/08 21/12/07 28/02/08 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 Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 28 Kirby House Mental Nursing Home DS0000017677.V356863.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Inspection Team Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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.V356863.R01.S.doc Version 5.2 Page 30 - 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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