Inspection on 05/08/05 for Kirby House Mental Nursing Home

This inspection was carried out on 5th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 21/12/05

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 135 West Street Dunstable Bedfordshire LU6 5SG Lead Inspector Ansuya Chudasama Announced 5 August 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Kirby House Mental Nursing Home Address 135 West Street Dunstable Bedfordshire LU6 5SG 01582 662609 01582 863056 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Southern Cross Care Homes Ltd Christopher Karigambe CRH (Care Home) 7 Category(ies) of N (Care Home with Nursing registration, with number MD(E) of places Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11.03.2005 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 I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 7 hours. The registered manager was off sick and the deputy manager had been acting up as the manager of the home since the 30th May 2005. The new operations manager was also present at the inspection. The inspector spent the majority of the inspection observing practice and speaking to service users and staff. The care records of two service users and other documents were also examined, and two service users bedrooms were inspected. Feedback was given to the acting manager. Southern Cross Care Homes LTD had recently taken over the management of the home from Highfield Care Homes Ltd What the service does well: What has improved since the last inspection? Some of the requirements were met from the last inspection. Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 6 What they could do better: 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 I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5,6. The home’s statement of purpose and service users’ guide provided potential service users, and their representatives with details of the services and facilities the home provided. This enabled them to make an informed decision about admission to the home EVIDENCE: The home had a statement of purpose and a service users’ guide. The guide was being produced in a user-friendly format. Each service user was provided with a contract and this was signed by the service user. The home had not admitted any new service users to the home for many years. It was stated that all service users had their needs assessed prior to moving into the home on a permanent basis. The home did not provide intermediate care or took emergency admissions. Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 The care plans illustrated that service users received good standards of care. Conversations with service users showed that their needs were being met EVIDENCE: All service users in the home had care plans. Those inspected showed that the service users personal and health care needs were being met. The information was well recorded. However the audit review form for one service user had not been completed properly. Service users spoken to stated that the staff accompanied them to their appointments and found them very helpful. The staff spoken to understood the needs of the service users well. Risk assessments were also undertaken for all the service users. The plans were being reviewed on a monthly basis. All the service users were registered with a local GP. The home had a policy on medication. None of the service users administered their own medication. The registered nurses gave out medication. Records were seen for medication received, administered and disposed of to ensure that there was no mishandling. The service users spoken to stated that staff knocked on their doors before entering their room and one stated that she got a “nice cup of tea in the mornings”. The service users’ files seen had information on burial arrangements and the home had policies and procedures on death and dying. The staff spoken to had experience in dealing with ageing illness and death. Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 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 standard(s) 12,13,14,15. Service users were offered varied and nutritious meals to ensure they remained healthy. The home provided weekly activities and monthly social events so service users could enjoy a normal range of activities. EVIDENCE: The service users were given opportunities to exercise their choice in relation to leisure activities, meals, and routines of daily living. The homes activities coordinator left in March 2005 and later returned to the home to work as a bank staff. The acting manager informed the inspector that this position was being advertised on a permanent basis. On the day of the inspection, the service users were observed listening to music, watching television, talking to staff and helping the activities organiser with making biscuits. One service user was seen having her nails painted and another service user went out shopping with staff. One service user went to day centre. There were pictures and paintings and ornaments made by the service users displayed around the house. Service users meetings were undertaken and the running of the home was discussed. The home reviewed the activities undertaken by service users on a monthly and yearly basis. However this information needs to be recorded in the care plan. The service users informed the inspector that the meals provided were very good and they were able to choose other options if they did not like what was on the menu. The staff and the cook spoken to were aware of service users likes and dislikes of food and activities. Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 11 Service users were encouraged to maintain contact with their families by staff. Records showed that service users visited their families and they also visited the home. This information needs to be recorded in the care plan Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18 There were systems in place to ensure that service users were protected and complaints were listened to and dealt with satisfactorily. EVIDENCE: The home had a complaints policy but needed reviewing to meet the standard. The home had not received any complaints. The acting manager stated that the complaints policy was given and explained to service users. The service users spoken to stated that they would speak to carers and the nurses if they were unhappy. The home had a policy on adult abuse but this needed reviewing to meet the standard. Service users spoken to were able to make decisions about their lives. One service user had made a decision to spend most of her time in her bedroom. The staff respected the service users decision. Service users next of kin and other professionals were also involved in planning for their care needs. This also ensured that service users had a say in how their care was given by staff. The adult protection policy needed reviewing to meet current guidelines. Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,23,24,25,26. The environment was clean, well maintained, and comfortable and met service users needs. EVIDENCE: Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 14 The home was clean and tidy on the day of the inspection. A service user stated that the atmosphere of the home was like living in “ a small cosy home”. Service users were offered keys to their bedrooms, however they all declined the offer. Service users’ stated that they liked their bedrooms and they had chosen the colours for their rooms. One service users mattress had not been replaced as stated at the last inspection. The nets had also not been replaced. The inspector was informed that the estate manager from the organisation had undertaken a review of the building. Some of the recommendations had been implemented. The fence and the stairs had been repaired. The hatch in the kitchen had been closed as instructed by the fire officer. The three fire doors that did not close properly had been repaired. The review of the layout of the dining room was still being sorted. Most of the clutter had been removed. The service users had chosen new table and chairs for the dining room. The flood in the office, which was in the cellar, was being dealt by the organisation. Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. There were sufficient numbers of staff with relevant training to ensure that the needs of the service users were met. EVIDENCE: The members of staff spoken to had received job descriptions and a contract. The staff had been working at the home for over 7 years and provided continuity to service users. They also gave detailed information in how they cared for the service users at the home. The staff had completed all the mandatory training in safe working practices. One staff was completing her NVQ level 3 in care. However she needed training in epilepsy, and challenging behaviour. They understood information on adult protection, and they stated that the service users were able to tell them if they were unhappy. Service users spoken to confirmed this. The care staff spoken to stated that the nurses implemented the care plans and they also wrote in the daily notes of the service users. The organisation needs to get the care staff more involved in this practice. The staff files inspected showed that one staff did not have an up to date job description, or had references. The staff stated that they enjoyed working at the home and with the service users. It was also stated that the service users were well cared for by them Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,36,38. The home was well managed to ensure the needs of service users were met. EVIDENCE: The registered manager had been off sick since the 30th May 2005. The deputy manager was promoted to the role of acting manager. The acting manager stated that she was being supported the operations manager. The acting manager found it difficult to get all the responsibilities completed within the hours allocated to undertake her role. The inspector had a discussion with the operations manager about managers working hours to ensure that s/he has sufficient supernumerary hours to undertake the management responsibilities stated in the standard and in their job description. It was stated that this was being reviewed by the organisation. One staff stated that they had supervision three times a year. However, this needs to be carried out at least six times a year. In formation in supervision needed expanding as stated in the standard. The staff spoken to stated that the acting manager was very helpful and they could talk to her any time. The service users also Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 17 found the acting manager very helpful. The fire alarms were tested on a weekly basis. Emergency lighting was also tested on a monthly basis. The staff and service users spoken to stated that they had regular fire drills and knew what to do if there was a fire. There were no accidents or incidents recorded for service users’ who were case tracked. Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 3 x x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x 3 2 x x 2 x 3 Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 19 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 OP33 Regulation 24 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 The registered person must ensure that the information required in Schedule 2 and 4 is available in the home The registered person must review the policy on adult protection Timescale for action 28th February. 2005. 12th May 2005. New date 13th September 2005 31.Septem ber 2005. 28th February 2005. 12th May 2005. 31.Septem ber 2005 2. OP29 3. OP18 17.22 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 OP30 Good Practice Recommendations Provide all staff training on agression and epilepsy. I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 20 Kirby House 2. 3. 4. OP24 OP24 OP36 Provide matching curtains and bedding for some of the service users. Replace the worn out matressa and nets in the downstairs bedroom. Provide staff with at least six supervisions per year. Kirby House I51 S17677 Kirby House V231387 050805 - Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Clifton House 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. 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