Inspection on 18/08/05 for Kirkby Manor Care Home

This inspection was carried out on 18th August 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

Kirkby Manor Care Home 26/07/07

Kirkby Manor Care Home 16/07/06

Kirkby Manor Care Home 04/10/05

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

CARE HOMES FOR OLDER PEOPLE Kirkby Manor Care Home Beech Avenue Kirkby in Ashfield Nottinghamshire NG17 8BP Lead Inspector Richard Ramsden Unannounced 18/08/05 10.30 am 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. Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Kirkby Manor Care Home Address Beech Avenue Kirkby in Ashfield Nottinghamshire NG17 8BP 01623 723724 01623 723724 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) Hallmark Healthcare Pauline Waddups CRH 40 Category(ies) of 40 MD(E) registration, with number of places Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 8th September 2004 Brief Description of the Service: Kirkby Manor is a purpose-built 40 bedded care home offering specialist care for older people with mental illness. Qualified nursing care is provided at all times. The home is located in a cul-de-sac in a residential area of Kirkby in Ashfield, the town centre is approximately half a mile away. The accommodation is on two floors with a passenger lift to assist independent access. All of the bedrooms of all single occupancy. There is a safe enclosed garden which is accessible by residents. Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector completed this unannounced inspection over one day it took approximately 6 hours. It included the inspection of care and of the records, a brief discussion with two residents, two visitors to the home, three members of care staff and the deputy manager. A partial tour of the building was also completed. The main focus of the inspection was to assess the progress made in implementing requirements highlighted at previous inspections. What the service does well: What has improved since the last inspection? This is the first inspection completed at Kirkby Manor since the new owners purchased it. There have been a significant number of improvements since the last inspection. The lighting in some of the communal areas has been upgraded and additional handrails have been provided in all the corridors helping to reduce the risk of residents falling. The inspector was informed that a new carpet has been provided in one of the lounges and that a new hoist has been fitted to one of the bathrooms. It was also noted that new linen and other equipment has also been provided. A considerable amount of staff training has also been provided since the last inspection. (This is good practice). Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 Stage 4.doc Version 1.40 Page 6 At previous inspections it has been identified that there were malodours throughout the home. At the time of this inspection the home was appropriately clean and there were no malodours. 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. Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 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 Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 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) 3,4,6. The home is obtaining comprehensive pre-admission assessments for the residents admitted to the home. Staff have not ensured that all residents’ identified needs have appropriate actions planned, which ensures that the staff team provide care in such a way as to meet those needs. The home does not provide intermediate care. EVIDENCE: Appropriate pre-admission assessments had been obtained for all the residents whose records were assessed as part of this inspection. A requirement was made at the previous inspection to ensure that all needs identified have appropriate actions planned in order to ensure that the staff team carry out care in such a way as to meet those needs. This requirement had not been met. One of the resident’s pre admission assessment stated that he was at high risk of falling and that his skin was thin and that he was undernourished. No risk assessments for the prevention of falls or to assess his tissue viability had been included in this residents care plan. The home does not provide intermediate care although respite care will be provided when vacancies exist. Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 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. The residents care plans do not contain sufficient comprehensive information to ensure that all their personal and social care needs are met. The records viewed during the inspection demonstrate that appropriate referrals are being made to health care professionals. The medication administration records must be more comprehensively maintained to ensure that the system is safe for the residents. EVIDENCE: As previously stated the care plans viewed as part of this inspection did not contain sufficient information to ensure that staff are meeting all of the residents assessed needs. Two of the three care plans had not been reviewed on a regular basis and there was no evidence that residents or their representatives have been involved in the care planning and review process. One care plan viewed during the inspection stated that the resident was independently mobile however the inspector was verbally informed that this person’s physical condition had seriously deteriorated and that he is no longer able to mobilise at all. Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 Stage 4.doc Version 1.40 Page 10 The deputy manager stated that it is difficult to include residents in the care planning process as many people lack the capacity to comprehend the information. So, if there is no regular family involvement, the care plans are just reviewed by the staff. The inspector advised that care plans should be reviewed at least once a month and more frequently if the individual residents care needs change. The care plans must always accurately reflect the care and support each individual resident requires. Where care plans cannot be reviewed with residents or their representatives this information should be recorded on the individual residents file. The inspector accepts that staff are working hard to transfer residents records onto a new improved format which has been introduced by the new owners. While the new format will provide much more comprehensive information it is important that the existing records continue to reflect the changing needs of each resident. The new system for recording and medical intervention is clear and concise and should comply with all requirements when they have been introduced for all residents. The inspector noted that GP referrals and other medical referrals had been appropriate on the care records viewed during the inspection. The home’s medication was stored safely and the records of receipt and disposal of medication were well maintained. The inspector was advised that all medication is administered by qualified nursing staff. There were many occasions where the medication administration records had not been signed. The deputy manager was informed that they should be no gaps in the medication Administration records. If for some reason the medication is not given to the person for whom it is prescribed then an explanation must be provided. The use of codes is acceptable for this purpose. The inspector also advised that staff record the temperature in the room in which the medication is stored on a daily basis. The temperature must not exceed 25°C as the medication can deteriorate at higher temperatures. Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 Stage 4.doc Version 1.40 Page 11 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) None None of these standards were assessed as part of this inspection. EVIDENCE: Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 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) 16,18. The home could not provide evidence of how they have improved the staff teams awareness of the way in which complaints must be documented. All staff have now completed training in Abuse Awareness. EVIDENCE: The deputy manager stated that staff were informed, at a staff meeting, how complaints must be documented. However the minutes of this meeting could not be located at the time of inspection. The deputy manager was advised that the minutes must be located or alternative evidence provided and forwarded to the Commission Social Care Inspection. The inspector was advised that there have been no complaints received since the last inspection. The inspector was informed that all staff have completed training in Abuse Awareness, this was confirmed by those of the members of staff interviewed during the inspection. Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 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) 22,25,26. The lighting in all areas of the home viewed, during the inspection was of a good standard and handrails have been appropriately fitted throughout the corridors. The home was clean and there were no malodours at the time of this inspection. EVIDENCE: The inspector was informed that the new owners intend to completely refurbish the home. Since last inspection the lighting in some of the communal areas has been improved and additional handrails have been provided throughout the corridors. All of the bedrooms viewed during the inspection were clean, reasonably decorated and comfortably furnished. People had been encouraged to bring small items of furniture, photographs and ornaments to personalise their bedrooms. (This is good practice). Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 Stage 4.doc Version 1.40 Page 14 The deputy manager stated that a new carpet had been provided in one of the lounges and that a new hoist had been fitted in one of the bathrooms. The laundry is well equipped with industrial washing machines and tumble driers. The inspector recommended that the appropriate COSHH and Infection Control Policies should be displayed in the laundry. On the day of inspection the home was appropriately clean and there were no offensive odours. The relative spoken with during the inspection confirmed that they are satisfied with the level of cleanliness maintained within the home. Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 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) 29. The information provided in staff files has improved since the last inspection. At least one member of staff was employed before a Criminal Records Bureau Check had been applied for and confirmation has been received that the member of staff is not included on the Protection of Vulnerable Adults List. EVIDENCE: The personnel files of two members of staff were checked during this inspection. Both files contained copies of two references, a photograph of each member of staff and a copy of their birth certificates. There was evidence on one member of staffs records that a CRB checks had been applied for and that a POVA 1st check had been completed before she commenced employment. The second member of staff had provided a CRB check and had been allowed to commence work at the home while she was awaiting for a new CRB check to be completed. The CRB check provided was approximately 3 years old. The deputy manager was informed that no staff should commence employment until a new CRB check has been submitted and confirmation has been received that this person is not included on the POVA list. These checks must be implemented to help ensure that vulnerable residents are not put at risk. Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 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) 37,38. The residents’ accident records were being appropriately maintained at the time of this inspection. All staff are being provided with Moving and Handling Training. The qualified nurses employed at the home need to complete first aid training. EVIDENCE: The resident’s accident records were checked at random and were well maintained. 12 people have completed training in Moving and Handling and the remaining staff are completed training on the 19th of September 2005. (This is good practice). Staff training records show that the majority of staff have completed basic first aid training as part of their TOPPS training. However it was noted that none of the qualified staff have completed first aid training. Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 Stage 4.doc Version 1.40 Page 17 Nurse training does not equip staff to provide first aid training. The deputy manager was advised that all nurses should complete some form of first aid training. She was also reminded that there must be a member of staff on duty, in the home at all times, who has an up to date first aid qualification. Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 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 x x 3 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x 3 x x 3 3 STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x x x x x x 3 3 Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 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 4 Regulation 15.1 Requirement It is required that the registered person ensures that all identified needs have appropriate actions planned in order to ensure that the staff team carry out care in such a way as to meet those needs(This requirement is outstanding from 24/6/04. It is required that residents and where appropriate their representatives are involved in the care planing and review process. Where possible the plans should be signed by the resident/their representative. (This requirement is outstanding from the 24/6/04). It is required that residents care plans are reviewed at least once each month, or more frequently if the residents care needs change. It is required that medication records are signs each time the medication is given to a resident. If for any reason the medication is not given to the resident for whom it is prescribed an explanation must be provided. The use of codes is acceptable for this purpose. C03 C53 S63843 Kirkby Manor V244418 180805 Stage 4.doc Timescale for action 26th September 2005. 2. 7 15 Immediate 18/8/05 3. 7 15 Immediate 18/8/05 4. 9 13 Immediate 18/8/05 Kirkby Manor Care Home Version 1.40 Page 20 5. 9 13 6. 16 22 7. 29 19.4 8. 38 13.4 It is required that staff record, each day, the temperature in the room in which the medication is stored. The room temperature must not exceed 25 C. It is required that the registered person provide evidence of how the staff teams awareness of documenting complaints has been improved. The evidence must be provided to the commission for social care inspection. (This requirement is outstanding from 24/10/04) It is required that staff do not commence employment until a Criminal Records Bureau check has been applied for and confirmation has been received that the prospective member of staff has not been included on the POVA list. It is required that all staff are provided with first aid training. (This requirement is outstanding from 24/10/05) Immediate 18/8/05 26th September 2005 Immediate 18/8/05 17/10/05 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 7 Good Practice Recommendations It is recommended that where residents are unable to sign to confirm their involvement in the care planning and review process and they have no regular family contact this information is recorded in their care plans. Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Edgeley House Tottle Road Nottingham NG2 1RT 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 Kirkby Manor Care Home C03 C53 S63843 Kirkby Manor V244418 180805 Stage 4.doc Version 1.40 Page 22 - 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. 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