Inspection on 21/12/05 for Kirby House Mental Nursing Home

This inspection was carried out on 21st December 2005.

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 20/12/07

Kirby House Mental Nursing Home 12/03/07

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 Ansuya Chudasama Unannounced Inspection 14:00 21 December 2005 st 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.V272640.R01.S.doc Version 5.0 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.V272640.R01.S.doc Version 5.0 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 863056 Southern Cross Care Homes Limited Christopher Karigambe 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.V272640.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user can be placed in the home under the age of 65 years. 5th August 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.V272640.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place just over two hours. Jo Martin, the staff nurse in charge, assisted the inspector. The manager of the home was off sick. The inspection comprised of a tour of the home, looking at staff records, and checking that the previous requirements and recommendations were complied with. This report should be read in conjunction with the last inspection report undertaken on the 5/8/2005 What the service does well: What has improved since the last inspection? What they could do better: The registered person must ensure that effective quality assurance and monitoring systems are in place and an annual development plan produced. The tour around the lounge and the dinning room showed that the home Kirby House Mental Nursing Home DS0000017677.V272640.R01.S.doc Version 5.0 Page 6 needed more electric sockets. The home needs to provide staff with at least six supervisions per year. The bathroom on the ground floor needs redecorating and the wall at the far end had damp and needed attention. The downstairs hall wall near the bedroom also needed attention, as it was very damp. Regulation 26 visit reports were received by the CSCI but the information needed to be more detailed. Statements such as “seen” and ticks did not provide enough information regarding the standard of care provided in the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kirby House Mental Nursing Home DS0000017677.V272640.R01.S.doc Version 5.0 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.V272640.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 None of the standards were assessed on this occasion but these were assessed at the last inspection. EVIDENCE: Kirby House Mental Nursing Home DS0000017677.V272640.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 None of the standards were assessed on this occasion but these were assessed at the last inspection. EVIDENCE: Kirby House Mental Nursing Home DS0000017677.V272640.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 None of the standards were assessed on this occasion but these were assessed at the last inspection. EVIDENCE: Kirby House Mental Nursing Home DS0000017677.V272640.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18, The staff have good knowledge and understanding of adult protection issues to protect service users from abuse EVIDENCE: All the staff at the home had undertaken training on adult protection. The staff in charge gave examples of how she would deal with any kind of abuse in the home. The organisation had still not reviewed the policy on adult protection. The complaints book inspected showed that the home did not receive any complaints. The service users spoken to stated that they knew who to talk to if they were not happy or had any concerns. The staff on duty was unable to find the complaints procedure. It was stated that the policy was displayed on the dinning room wall. However the procedure was removed when the room was recently decorated. The inspector was unable to find out if the complaints policy had been revised to meet the standard as stated in the last inspection report. Kirby House Mental Nursing Home DS0000017677.V272640.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 23,24,25,26. The premises were safe so as to allow all those living at the home to enjoy a homely and comfortable environment that was clean, and hygienic EVIDENCE: The home looked very festive and the service users had chosen the decorations. The home had a new dining table and chairs. The dinning room was pleasantly decorated with new curtains, and it looked bigger and brighter. The tour of the home showed that the lounge and the dinning room needed more electric sockets. This was confirmed by talking to staff. The fridge in the kitchen was not big enough to cater for all the service users food. Another fridge was required. This was being discussed with management. The service users bedrooms seen were individualised and met their needs. One service user had an en-suite and the shower cubicle in the room was used for storing incontinence pads. These pads need to be kept in a cupboard to promote the service users dignity. The bathroom on the ground floor needs redecorating and the wall at the far end had damp. The downstairs hall wall near bedroom one was very damp. Kirby House Mental Nursing Home DS0000017677.V272640.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28,29,30 The home provided very good training so that the people living at the home had their needs met by competent and suitable staff EVIDENCE: The home was fully staffed and did not have any vacancies. The homes bank staff were used to cover staff sickness and holidays. Two staff files were inspected. The files had information required for the protection of service users. However one file did not contain a photograph of the staff. The inspector was informed that all staff had recently had their photographs undertaken to put in their files. The staff files had information about another home that the staff worked at prior to working at this home. The information was at times difficult to understand. The files had certificates of training undertaken by staff. The staff confirmed that they had good training. They had recently all attended training on aggression and epilepsy and abuse. The staff spoken to had worked at the home for many years and one member of staff had been at the home since it first opened. The service users spoken to stated that the staff are “wonderful” and they have time to “listen to them”. Kirby House Mental Nursing Home DS0000017677.V272640.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,36,38, The home had satisfactory health and safety procedures in place to ensure that the service users and staff were protected. EVIDENCE: The staff spoken to had received training on safe working practices. It was also stated that fire drills, fire alarm testing and emergency lightening was carried out regularly. This was confirmed by talking to service users who stated that a fire drill was undertaken last Saturday and they were all involved. The files inspected showed that supervision was not being undertaken at least six times a year. The supervision notes contained a tick chart, and there was no written evidence to show that all aspects of practice and the philosophy of care in the home was being discussed. Supervision notes at times did not have a date of when this was undertaken. Kirby House Mental Nursing Home DS0000017677.V272640.R01.S.doc Version 5.0 Page 15 The staff on duty was not able to find the quality audit and an annual development plan. The accident and incident book was inspected. The forms needed to be completed properly. Also the service users individual accident/ incident forms should be put in their individual files due to the Data Protection Act. Regulation 26 visit reports were received by the CSCI but the information needed to be more detailed. Statements such as “seen” and ticks did not provide enough information regarding the standard of care provided in the home. Kirby House Mental Nursing Home DS0000017677.V272640.R01.S.doc Version 5.0 Page 16 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 X 3 Kirby House Mental Nursing Home DS0000017677.V272640.R01.S.doc Version 5.0 Page 17 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 OP31 Regulation 10 Requirement The registered person must review the managers working hours to ensure that he has sufficient supernumerary hours to undertake the management responsibilities stated in the standard and in his job description. (This requirement was not assessed on this occasion as the manager was off sick) The registered person must ensure that effective quality assurance and monitoring systems are in place and an annual development plan produced. 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. Timescale for action 30/03/06 2. OP33 24 30/03/06 3 OP19 23 30/04/06 Kirby House Mental Nursing Home DS0000017677.V272640.R01.S.doc Version 5.0 Page 18 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. 2. 3. 4. 5 6 7 Refer to Standard OP16 OP18 OP23 OP36 OP36 OP33 OP19 Good Practice Recommendations Review the complaints policy and ensure that a copy is kept available in the home. Review the policy on adult protection. Ensure that service users incontinent pads are kept in a cupboard. Provide staff with at least six supervisions per year. Ensure that staff files are better organised. Ensure that regulation 26 visit reports are more detailed. Ensure that the bathroom down stairs is redecorated. Kirby House Mental Nursing Home DS0000017677.V272640.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kirby House Mental Nursing Home DS0000017677.V272640.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!