Inspection on 20/06/08 for Kirby House Mental Nursing Home

This inspection was carried out on 20th June 2008.

CSCI found this care home to be providing an Adequate service.

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 Mental Nursing Home 20/12/07

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Kirby House Mental Nursing Home 135 West Street Dunstable Bedfordshire LU6 1SG Lead Inspector Kathy Jones Unannounced Inspection 20th June 2008 10:20 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.V367118.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.V367118.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.V367118.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. 20th December 2007 Date of last inspection Brief Description of the Service: Kirby House provides care and support to six older people with mental health care needs. Southern Cross Care Homes Limited, a large national healthcare provider own Kirby House. Kirby House is a small home situated in a residential area near Dunstable town centre in the county of Bedfordshire. It is an extended family type house, with five single bedrooms and one shared bedroom. There are bedrooms on both floors. Access to the first floor bedrooms is via the stairs, which means that people need to be independently mobile. There is a shared 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. Information about the range of fees was not available at the time of the inspection and a requirement has been made about the availability of this information. Kirby House Mental Nursing Home DS0000017677.V367118.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Standards identified as ‘key’ standards and highlighted through the report were inspected. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of existing evidence, pre-inspection planning, an unannounced inspection visit to the home, collating information received in surveys and drawing together all of the evidence gathered. The pre-inspection planning was carried out over the period of half a day and involved reviewing the service history, which details all contact and correspondence with the home and previous inspection reports. The last full inspection took place in December 2007. A meeting was then held in March 2008 with the Responsible Individual to discuss the requirements relating to the environment. This unannounced inspection visit was carried out over the period of a approx four and a half hours covering the late morning and early afternoon. On this occasion this was a weekday. The inspection was carried out by ‘case tracking’, which involves selecting samples of people’s records and tracking their care and experiences. Observations of the homes routines and care provided were made. Discussion took place with people who use the service and their views have been taken into account as part of the inspection. Additionally questionnaires were sent to a random selection of people to ascertain their views. At the time of completion of the report, responses had been received from two people who use the service and two members of staff. Their views have been considered as part of the inspection and some comments incorporated within the report. The management of people’s medication was checked through reviewing prescribed medication for a sample of people. A sample of staff files were reviewed to check the adequacy of the recruitment procedures in protecting people who use the service. Communal areas and a sample of bedrooms were viewed. Some brief verbal feedback was given to the Registered Manager during the inspection. Further feedback was given by telephone following the inspection. People who use the service and staff had planned to go out for coffee and Kirby House Mental Nursing Home DS0000017677.V367118.R01.S.doc Version 5.2 Page 6 cakes at 3pm. It was therefore agreed that it was unfair for the inspection to disrupt their plans. What the service does well: What has improved since the last inspection? What they could do better: It is important that information such as the statement of purpose and complaint procedure are reviewed and updated to ensure all information is current and accurate. The management of medication and associated records needs some improvement to ensure people receive their medication as prescribed. Kirby House Mental Nursing Home DS0000017677.V367118.R01.S.doc Version 5.2 Page 7 Advice has been given that records relating to any investigations such as those involving safeguarding issues should be kept available for inspection, as it was difficult to see the actions that had been taken. The adequacy of the premises in meeting people’s needs particularly in the medium and long term remain an issue for concern. However the detailed occupational health report provides a good basis for future planning and it is requested that a copy of an action plan developed from this is shared with the Commission for Social Care Inspection and any other relevant parties. 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.V367118.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.V367118.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. Std 6 is not applicable, as intermediate care is not provided. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are happy with their choice of home and the information they received. However the information available to people does not contain all of the required information and in some cases is not up to date. EVIDENCE: There is a statement of purpose and a service user guide. This information is available to people who use the service who each have copies in their rooms. A sample check of the documentation identified that it is out of date, for example there is reference to a previous manager and the complaint procedure gives the address of the organisation that owned Kirby House prior to Southern Cross. The documents were not checked in full, as it was evident that a full review of the documentation is required so that people have clear and accurate Kirby House Mental Nursing Home DS0000017677.V367118.R01.S.doc Version 5.2 Page 10 information about the service. It is recommended that as part of the review consideration is given to providing the information in a format that is accessible to people who use the service. Advice was given following the inspection in December 2007 that the service user guide should contain information about the laundry room being accessed through a ‘service users’ bedroom. While these arrangements do not meet the National Minimum Standards, Kirby House was registered prior to the implementation of these standards. However it is important that areas where National Minimum Standards are not met due to limitations of the premises are detailed within the statement of purpose. This is to help ensure that people are able to make informed choices. Information about the fees and additional costs are not currently included within the service user guide. This is important to ensure that arrangements are transparent, choices can be made and finances planned. Two people spoken with during the inspection were satisfied with the information they had and very clear about the fact that they liked living at Kirby house and were very happy with their choice of home. One person who completed a survey stated “I tried different homes this is the best”. The annual quality assurance self assessment identifies that a thorough assesment of peoples needs is carried out prior to admission to make sure that their needs are fully met. Discussion with the Registered Manager identified that the majority of people have lived at Kirby House since 1998 and that noone has been admitted since 2002. There are no plans to admit anyone else at the present time. Currently Kirby House is registered for seven people, however given the limitations of the premises the registered manager feels it is more suited to six people. The occupancy has remained at six for several years, therefore advice was given to consider requesting an alteration to the registered numbers. Kirby House Mental Nursing Home DS0000017677.V367118.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People receive a good level of care and support, however more careful record keeping in relation to the management of medication is needed to reduce the risk of people not receiving medication as prescribed. EVIDENCE: People spoken with during the inspection were happy with the care and support that they receive. A sample check of the care plans for someone who uses the service identified that these provided clear information and guidance to staff in relation to the care to be provided. The care plans covered people’s physical and mental health needs. The plans were evaluated regularly. Surveys received from two staff members confirmed that they always have up to date information about the needs of the people they support or care for. One stated that “care plans are very comprehensive” and also said that information is shared at the change of each shift. Detailed care plans and up Kirby House Mental Nursing Home DS0000017677.V367118.R01.S.doc Version 5.2 Page 12 to date information about people’s needs is important in helping to ensure that their needs are met. The annual quality assurance self assessment (AQAA) confirms that people have access to health care services. There is also evidence that people are given choices about treatment as mention is made of trying to encourage more people to see the dentist. It is important that people’s rights and choices are taken into account alongside working to ensure that their health care needs are met. Surveys from two people who use the service confirm that they always receive the medical support that they need. Previous inspection reports have identified concerns about the suitability of the premises in relation to people’s changing needs as they become older. This is discussed in the section on the environment in this report, however it is important that this is linked to people’s health care needs and that information based on recent occupational health review commissioned by Southern Cross is taken into account as part of this. This will help to ensure that people’s needs are met and risk reduced. A sample check of the management of medication confirmed that people’s prescribed medication was available. Most of the medication is received from the pharmacist in blister packs, which identify the date to be given. These were checked against the records of medication received and administered for one person and found to be correct. However a check of some medication received from the pharmacist in packets found a discrepancy of one tablet for one of the medications and a gap in the recording for another. There is a system where medication is audited monthly, however it is important that records are accurate and any errors checked immediately to ensure people always have their medication as prescribed. There is a list of staff signatures available which is designed to enable any errors to be quickly checked, however the signatures on the list were not in the same format as the list. The list contained full signatures, whereby initials were used on the medication administration record, making it difficult to check any mistakes. Two people spoken with during the inspection confirmed that staff treat them with dignity and respect. During the inspection staff were heard to be respectful in the way they addressed people. Kirby House Mental Nursing Home DS0000017677.V367118.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. People are satisfied with their daily lives at Kirby House. EVIDENCE: People who use the service were very keen to say that they are very happy living at Kirby House. There is a very relaxed ‘homely’ atmosphere in the house with lots of conversation between staff and people who use the service. Care plans identify people’s preferred routines, for example times they like to go to bed, whether they like to have nightly checks and one identified that the person liked to have cups of tea if they couldn’t sleep. This is important in helping to ensure that people’ s individual preferences are met. People are supported according to their individual needs. One person attended a day centre on the morning of the inspection and another talked about going out independently. The annual quality assurance self assessment identifies that people are accompanied to places they are not confident to go on their own and that Kirby House Mental Nursing Home DS0000017677.V367118.R01.S.doc Version 5.2 Page 14 people are actively involved in community activities, using the available facilities like library, churches etc. On the day of the unannounced inspection it was planned that people would go out with staff for coffee and cakes in the afternoon. Surveys from two people who use the service confirmed that there are activities that they can take part in. One said they like to go for walks and like to sit and read, joining in activities with the others sometimes. The other identified various board games. People were seen to be taking part in these activities during the inspection. The annual quality assurance self assessment identifies that people are able to keep in contact with relatives and friends by telephone and have visitors when they wish. One person who uses the service was looking forward to going to a family wedding. Two people who use the service stated in surveys that they always like the meals and one said “We have a fantastic chef the meals are delicious”. This was confirmed by people during the inspection, they also said that people’s preferences and any religious and cultural needs are taken into account. The previous inspection report identifies that discussion took place with the manager about the possibility of getting the people in the home to choose the menus by using pictures. People who use the service said that they had discussed this but preferred things the way they were in that the cook discusses the menus and any preferences with them. Kirby House Mental Nursing Home DS0000017677.V367118.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. People who use the service confirm that they know who to talk to if they have any concerns, however information about how to raise concerns outside Kirby House needs to be correct to ensure that people are properly safeguarded. EVIDENCE: No complaints have been received by the Commission for Social Care Inspection (CSCI) since the last inspection and the annual quality assurance self assessment confirms that no complaints have been received directly by Kirby House. CSCI were notified by Kirby House of an incident which had been reported and had been referred as appropriate through safeguarding adult procedures. As agreed with social services safeguarding adults team an internal investigation had taken place. At the time of the inspection the investigation had been concluded, however records of the investigation were not available for inspection. Confirmation of the outcome of the investigation has been received following the inspection. It is important that all allegations and incidents are thoroughly investigated and that records are in place to demonstrate that vulnerable people are being properly safeguarded. Kirby House Mental Nursing Home DS0000017677.V367118.R01.S.doc Version 5.2 Page 16 The annual quality assurance self assessment states that the complaint procedure is explained to people who use the service at meetings which are held every two months. Surveys from two people who use the service confirmed that they know who they can talk to if they are not happy and how to make a complaint. As detailed in the ‘choice of home’ section of this report, an out of date complaint procedure with incorrect contact details for people wishing to raise concerns outside Kirby House was found in the service user packs. It is important that people are provided with correct information in a format that is accessible to the individual to help ensure that they are properly safeguarded. Staff training records show that all staff have received training about abuse, most of them within the last few months. This helps to ensure that they are aware of their responsibilities towards the people that they care for. The Registered Manager advised that she is exploring advocacy services in the area with a view to providing people with the option of talking to an independent party. This would provide additional safeguards. Kirby House Mental Nursing Home DS0000017677.V367118.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, 21, 22, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are very happy with the living at Kirby House, however plans need to be put in place to ensure that people’s needs can be fully met and that unnecessary risks are avoided. EVIDENCE: Kirby House is an extended family house in a residential area. The people who live there have lived there for many years, the most recent having lived there for six years. People were very keen to say how happy they were living at Kirby House. Concern has been raised in previous inspection reports about the suitability of the premises as people are becoming older and their needs are changing. Requirements have been made following the inspections about the need to Kirby House Mental Nursing Home DS0000017677.V367118.R01.S.doc Version 5.2 Page 18 adapt the premises to meet people’s needs. A meeting was held with the Responsible Individual for Southern Cross in March 2008 to discuss the requirements and the difficulties with adaptations to the premises. Following the meeting, Southern Cross commissioned an occupational therapy assessment of the premises in relation to the needs of people living there. A very detailed report has been produced which identifies short, medium and long term improvements that can be made to the premises to meet the needs of the people living there. The premises do provide some difficulties for people whose mobility is poor. Examples of some of these include the fact that although two of the bedrooms are on the ground floor, four people are accommodated in rooms on the first floor. Access is via fairly steep stairs. Bathing facilities consist of domestic type facilities which at least one person has difficulty accessing when their mobility decreases during a period of mental ill health. The Registered Manager advised that quotes had been obtained for altering the ground floor bathroom to a ‘wet room’, which would be more accessible for people. As an interim measure Specific requirements relating to the premises and adaptations are not repeated in this inspection report as it is considered more appropriate for the organisation to review the recommendations in the occupational therapy report and develop an action plan based on this. The plan should detail how it is intended to meet people’s needs at least in the short and medium term, though it is expected that consideration is also given to the long term needs of people. It is recommended that a copy of the action plan is submitted to the Commission for Social Care Inspection and that consultation takes place with people who use the service, their relatives and placing authorities. Risk assessments will need to be maintained and regularly reviewed during this period with contingency plans put in place for any changing needs. Requirements were made at the last inspection about the lack of heating and damp in the bathroom, which kept re-occurring. It was of great concern that these issues had been ongoing problems, which had not been addressed. However a new boiler has now been fitted and the Registered Manager advised that some guttering was replaced as this had been identified as the cause of the damp. There was no evidence of damp at the time of this inspection. The environment was clean and comfortable and people who use the service confirmed that it is always fresh and clean. One person requested that we made a particular point of saying in the report that it is always “lovely and clean”. They also wanted it pointed out that there are never any unpleasant smells, which was confirmed from a sample check of the premises. Kirby House Mental Nursing Home DS0000017677.V367118.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, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements meet the needs of people who use the service. EVIDENCE: Observation during the inspection confirmed that there are very good relationships between staff which includes, nursing, care, cook and cleaner. All were chatting with people as they went about their various duties, creating a relaxed, friendly and comfortable environment. Surveys from two people who use the service confirmed that staff are always available when they are needed and that staff listen and act on what they say. This was confirmed through conversations with them during the inspection. Feedback from one member of staff was that there are always enough staff, while the other said there usually are. Information received from staff, the annual quality assurance self assessment and the staff training matrix confirms that there is a programme of training which helps to ensure that staff have the necessary knowledge and skills to meet people’s needs. Kirby House Mental Nursing Home DS0000017677.V367118.R01.S.doc Version 5.2 Page 20 Surveys received from two staff members confirmed that checks such as criminal record bureau clearances and references were carried out before they started work. A sample check of the files for two members of staff identified that the recruitment procedure had included obtaining criminal record bureau clearances and references for both of them. However information received for one member of staff indicated that a full employment history may not have been obtained and the Registered Manager was advised to check this further. This is important in helping to ensure that people are properly safeguarded. Kirby House Mental Nursing Home DS0000017677.V367118.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, 37, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager works in the best interests of the people who use the service. EVIDENCE: The Registered Manager is a nurse trained in mental health, she has a National Vocational Qualification at level 4 in care and completed her registered managers award in November 07. The Registered Manager presents as being approachable. Staff confirm that they meet regularly with her and someone who uses the service states that if Kirby House Mental Nursing Home DS0000017677.V367118.R01.S.doc Version 5.2 Page 22 they are not happy that they “speak to Nurse Neo”. Neo is the Registered Manager. Reference was made in the last inspection report to the fact that the Registered Manager only has six hours per week supernumerary time in which to carry out her management duties. It was confirmed that the number of hours remain the same. It is important to keep this under review to ensure that the responsibilities of the registered manager and the needs of people who use the service are met. The quality assurance process was not looked at in full during this inspection. However there was evidence that regular audits are carried out which includes looking at the management of people’s medication. Monthly unannounced visits are also carried out by an Operations Manager for Southern Cross to check on and report to the organisation on the quality of care provided. These visits include gathering the views of people who use the service. It was identified during the inspection in December 2007 that the Commission for Social Care Inspection (CSCI) had not been notified of problems with the heating system, which had resulted in it being out of action for several months. The Care Homes Regulations 2001 require that all such events that affect the welfare of people are notified to CSCI. Confirmation has been given to CSCI that the issues surrounding this failure to comply with the regulations have now been resolved. Training records confirm that staff receive training in safe working practices helping to protect the health and safety of people who live at Kirby House. The main health and safety issues appear to relate to the premises due to the changing needs of people. This issue has been discussed in the environment section of this report. Kirby House Mental Nursing Home DS0000017677.V367118.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 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 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 2 17 X 18 3 2 X 2 2 X X X 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 X X X 3 Kirby House Mental Nursing Home DS0000017677.V367118.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 4 Requirement Timescale for action 30/09/08 OP16 2. OP1 5 (1) (bb, bc, bd) 3. OP9 13(2) The information within the statement of purpose including contact details to make a complaint must be kept up to date. This is to ensure that people have access to accurate information. The service user guide must 30/09/08 include details of the fees and any additional charges. This is to ensure that there is transparency. There must be an accurate 15/08/08 record of medication received and administered. This is to help ensure that people’s prescribed medication is safely managed. A similar requirement with a timescale for compliance of 29/01/08 has not been met. Kirby House Mental Nursing Home DS0000017677.V367118.R01.S.doc Version 5.2 Page 25 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 OP19 OP21 OP22 Good Practice Recommendations A copy of the action plan based on the occupational therapists report should be submitted to the Commission for Social Care Inspection to demonstrate the action being taken to meet people’s needs. Kirby House Mental Nursing Home DS0000017677.V367118.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team 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. 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