Inspection on 26/07/07 for Kirkby Manor Care Home

This inspection was carried out on 26th July 2007.

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 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

Kirkby Manor Care Home 16/07/06

Kirkby Manor Care Home 04/10/05

Kirkby Manor Care Home 18/08/05

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 Steve Benson Key Unannounced Inspection 26th July 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kirkby Manor Care Home DS0000063843.V343862.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. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirkby Manor Care Home Address Beech Avenue Kirkby In Ashfield Nottinghamshire NG17 8BP 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) 01623 723724 01623 753931 kirkby@hallmarkhealthcare.co.uk www.hallmarkhealthcare.co.uk Hallmark Healthcare (Kirby in Ashfield) Ltd Ms Pauline Waddups Care Home 40 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (40) of places Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within category DE/E Date of last inspection 16th July 2006 Brief Description of the Service: Kirkby Manor is a modern, 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 easily accessible by residents. The manager said on 26/07/07 that the fees for the service range from £380 £580 per week depending on dependency needs. There are additional charges for hairdressing and chiropody. Further information about the home is available in the brochure and service user guide or from the website: www.hallmarkhealthcare.co.uk. The manager welcomes any telephone enquiries and a copy of the latest inspection report is available in the entrance foyer. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit to the home since 1st April 2007 by the Commission for Social Care Inspection. Prior to the visit an analysis of the home was undertaken from information gathered over the last year including that from the Annual Quality Assurance Assessment they completed. The site visit lasted for 6 hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the manager, the deputy manager, staff on duty and care practices were observed. A visitor was spoken with during the visit. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. The registration certificate was checked and found to be incorrect and a replacement one has been requested. What the service does well: Prospective new residents are assessed either during a visit to the home, or in their current surroundings to make sure that the home is able to meet their needs. Staff from the home contact healthcare professionals to see to the healthcare needs of residents and their health is monitored through observation and regular health checks. Medication is given out following the recommended safe procedures to make sure that residents are not put at risk when being given their medication. Residents are provided with the support they require and are not rushed. Visitors are welcome to come to the home at anytime so residents can keep in contact with family and friends. Residents are able to choose how they spend their time and are supported by staff to make choices where they are able so that residents remain in control of their lives as much as they are able. There is a complaints procedure, which is available for residents to use and policies and procedures for staff to follow if they suspect anyone is not being properly treated. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 6 The home is spacious and suitable for people using a wheelchair. Everywhere is kept clean and tidy, suitably decorated, appropriately furnished and kept in a good state of repair; as a result residents live in a safe and well-maintained environment. There is always at least 7 care staff and 2 nurses on duty during the day and 3 care staff and 1 nurse at night. Regular training is provided. New staff can only start work when the required checks have been carried out, including a satisfactory Criminal Records Bureau or Protection of Vulnerable Adults check. There is a suitably experienced manager in post who is working towards a recognised qualification and residents are able to express their views on how the home is run through completing questionnaires. The home will hold money for residents so they can make any purchases they want to. All transactions are signed for and witnessed to safeguard resident’s financial interests. What has improved since the last inspection? What they could do better: Ensure that all assessment information is available and that assessments are dated when completed. Care plans must clearly describe how residents’ needs are to be met and where a need is identified a care plan must be written for this so that staff know how to meet residents’ needs. Resident’s cultural needs must be addressed, including through activities provided and diet. The lift must be in full working order and not become stuck between floors. Please contact the provider for advice of actions taken in response to this Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 7 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. Kirkby Manor Care Home DS0000063843.V343862.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 Kirkby Manor Care Home DS0000063843.V343862.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): 3 and 6 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New residents are fully assessed prior to moving into the home to ensure that their needs can be met. The home does not offer an intermediate care service. EVIDENCE: A recently admitted resident was one of the people case tracked and there was a pre admission assessment completed by staff from the home using a pre assessment form on file, which had not been dated to show when it had been completed. There was also a health needs assessment completed by the National Health Service, which the date showed had been faxed to the home after the resident had been admitted. There was reference to an assessment completed by Social Services but this was not on the file. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 10 The manager said the home’s pre admission assessment had been completed prior to the resident coming to the home and said that this should have been dated. The manager said the normal process following an enquiry about a placement, is to arrange for information about the home to be sent out and then a nurse will go to see the applicant and carry out a pre admission assessment. Information is also gathered from other agencies involved including the health service and social services. Staff said that they are told about any new admission prior to them moving into the home and they are able to look at the assessments. A visitor said her relative had been visited in hospital prior to coming to the home, which was confirmed by the resident. The manager said that anyone is welcome to apply for a place providing they fall within the registration category for the home. Information provided on The Annual Quality Assurance Assessment showed that there are male and female residents at the home, the majority of whom are of white British origin, and two residents of Polish origin. There is no arrangement made for the home to provide an intermediate care service. Kirkby Manor Care Home DS0000063843.V343862.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 and 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ health, personal and social needs are met by care practices in the home, but there are not working care plans at present. Residents are treated with respect. EVIDENCE: A sample of three care files were looked at and these were well structured. They included the pre admission assessment, a life story, risk assessments, care plans, a moving and handling profile and monitoring forms. There was an index to care plans for easy reference, and there were plans for things such as falls, continence and personal hygiene. There was a form to record all personal hygiene given and a relative’s communication sheet. Risk assessments seen included ones for nutritional intake, tissue viability, choking and falls. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 12 The plans seen had not been fully completed and there were a number of gaps on the forms, including information of residents’ ethnic origin, the date of admission to the home and the name of the person completing the plan. There were some needs seen in the pre assessment information that did not have care plans, for example one resident was said to be frightened of using lifts and frightened of storms but there were not any plans of care for these. There was not a care plan for meeting the cultural needs of residents who are not of British origin. The manager explained the reason plans were not fully completed was because they are currently changing over to the new planning system, and they expect these to be completed by the end of the month. The intention is to bring all the information held on residents together in one place and this has taken some time to transfer over. The manager said that nursing staff complete care plans for residents receiving nursing care and senior care staff for those receiving residential care. A relative had signed one care plan seen and comments made in the relative’s communication sheet that they agreed with the care plan. Staff spoke of using care plans to get to know new residents and said they found the life story useful and described the care needs of case tracked residents. A visitor said they had discussed their relatives care plan and a resident said, “I have discussed it with my social worker”. There was a form to record any medical appointments on, however there were no entries on these for the residents’ case tracked. The manager said this was because they were not starting to use these until next month when the new care files start. The manager said that the psycho geriatrician would come to the home when requested as well as calling in on occasions to see how things are. The manager said that residents have health checks by the practice nurse when they reach 75 years old and they will arrange for annual flu jabs to be given. Staff said that a doctor is called if someone is unwell and that the district nurses visit the home. Other routine healthcare appointments are arranged including sight tests and a chiropodist was visiting the home. Staff described being able to recognise when someone with limited communication was feeling unwell. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 13 A visitor said her relative is waiting for an operation and she is kept informed when any medical attention is needed. A resident said, “The doctor comes if needed and I have had my eyes tested. The chiropodist comes every now and then and if I need a dentist I can see one”. A member of staff was seen arranging for a pair or glasses belonging to a resident to be taken to be repaired at the opticians, as they were broken. Part of both the morning and lunchtime drug round was observed and the correct procedures were being followed. The Medicine Administration Records were fully completed and there were photographs attached to these to aid with identification. The nurse giving out medication said that if a gap is noticed in the Medicine Administration Records this is reported to the manager, but this doesn’t happen very often. The manager said that only trained nurses give out medication and that one nurse is responsible for ordering all medication and returning any that has not been used. Staff said they do not give out medication but will help encourage residents to take it if they are reluctant. Staff were seen treating residents in a respectful manner throughout this visit. This included talking discreetly about personal matters, closing doors and paying attention to their appearance. The manager said that respecting privacy and dignity is included in staff training and senior staff watch the practices of staff to en sure these are respectful. Staff described good practices in promoting residents’ privacy and dignity including closing doors, asking them if they want assistance, holding personal conversations in private and reducing embarrassment when providing personal care. A resident said, “I have my own key to my room. I am treated with respect”. The resident was seen locking her room and staff were seen locking the room of another resident. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 14 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 and 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have opportunities to satisfy their social, religious and recreational interests and needs through opportunities provided within the home but this is not the case for their cultural needs. Residents are helped to exercise choice and control over their lives. Residents receive a wholesome and balanced diet but mealtime arrangements could be improved. EVIDENCE: Staff were seen speaking with and helping residents in an appropriate manner. They took time to assist residents in a manner they wished, for example one member of staff stayed with one resident when she had wanted more time until she felt ready to move from the dining room table. The member of staff talked about gardens and flowers with the resident until she was ready and then helped her. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 15 A new activities coordinator has taken up post and said she is finding out the sort of things residents like to do. There was an activities programme in the foyer, which the activities coordinator said she would be redoing shortly. A church minister visits the home and provides communion to any residents who wish to receive it. The activities coordinator was seen offering a variety of individual and group activities to residents, including dominoes, cards, nail care and exercising with a beach ball. Some residents were reluctant to join in the exercise session and the activities coordinator appropriately encouraged them to take part. The activities coordinator said a record is made of all activities residents take part in, but this was not seen. Care staff were also seen providing nail care and offering residents things to do such as drawing and colouring. Staff said that an entertainer comes once a week, which residents enjoy and they get books for residents to read. Residents also enjoy watching films and listening to music. All the activities provided are geared towards the needs and interests of white British residents and activities should be available for residents from other cultures. A visitor said her relative would love the chance to see films and look at books about Poland. A resident said, “I enjoy it when the music is on”. There were photographs displayed of a recent trip to Matlock, which a resident said she had enjoyed. The manager said that residents have opportunities to go out on their own with staff shopping and one goes to visit their brother. A resident said, “We are able to go out with staff escorting us”. Staff said that visitors are welcome and can take residents out. A visitor said she could take her relative out if she wanted, but he chooses not to. There were references in care plans to offering residents choices, for example choosing what they are going to wear that day. Staff were seen offering residents choices over everyday matters such as where they wanted to be, what they wanted to do and what they wanted to eat and drink. One member of staff was seen spending a long period of time with Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 16 one resident finding out what he wanted to eat. This involved bringing various items of food to him to help him make the choice. Residents are able to have a cooked breakfast if they wish, and some residents were seen having poached egg on toast. Other residents were having cereal, toast or sandwiches. The home has a four-week menu and the main meal is at lunchtime. There is not a choice of meal but dishes include sweet and sour pork, diced pork and apple medley and sausages and leeks in gravy. There is a different type of fish on Fridays and a roast dinner on Sundays. A lighter meal is had at teatime with a buffet type of meal being served with soup and things like sausage rolls, scotch eggs and pork pie with crisps. A pudding is provided at lunch and teatime. Staff said that residents could always have an alternative to what is provided. There is not any food provided that originates from Poland and a visitor said it would be nice if her relative could have some native Polish food such as sauerkraut, roll mops, Polish sausages and bread as this would bring back memories for him. A resident said, “I enjoy sauerkraut, but it must be cooked properly, like I used to”. Lunch was seen served and this was corned beef pie with mixed vegetables and gravy followed by treacle sponge and custard. Some residents were having fish as an alternative and some residents had fruit or yoghurt for pudding. Drinks were provided with the meal. Staff spent time settling residents in the dining room and assisting some to eat. The dining room was a little cramped and was not laid out for the meal. The manager said that residents would remove tablecloths and cutlery. Some residents were wandering around whilst waiting for their meal, yet as soon as it was served at down and ate it. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 17 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 and 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place for residents to raise complaints and action is taken if any form of abuse is suspected. EVIDENCE: The home has a complaints procedure and there is a complaints book in the entrance foyer, but there were no entries made in this. There is also a suggestion box for residents, relatives and staff to use. The manager said that one relative had complained about the heat in the conservatory during hot weather and this had been acted upon, however it had not been recorded. Staff said that they had not dealt with a complaint but would take any made directly to the manager. A visitor also said she would take any complaints to the manager but has not got any. A resident said, “I haven’t had to complain, they will sort things out for me if I ask them”. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 18 One complaint was raised about the condition a resident was admitted into hospital. This led to an investigation under the Adult Protection Procedures and a member of staff was dismissed and referred to The Protection of vulnerable Adults register. There was a copy of the Adult Protection Procedures and the home has a whistle blowing policy. Staff said received training on safeguarding adults within the last 2 weeks. Staff said that external doors are alarmed so they know if a resident is trying to leave the building. A resident said, “I feel perfectly safe, one member of staff shows her dislike but that doesn’t worry me”. (The resident was not prepared to give any further details about this). Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 19 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 and 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a safe, well-maintained environment, which is clean, pleasant and hygienic. EVIDENCE: The home was clean and tidy and there were not any outstanding repairs noted. There were old time adverts such as Double Diamond and Brasso on the walls and a large clock in one of the lounges. There are handrails in corridors and all areas of the home are accessible to wheelchair users. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 20 There is a maintenance man employed to carry out minor repairs and staff said that these are attended to promptly. Staff also said that the toilets and bathrooms are suitable for providing residents with any assistance they require. There is some landscaping being carried out to an area of the garden which although unusable will provide a pleasant view when completed. A resident said, “It’s nice to have had the decoration done”. There were two different coloured protective aprons in use, one for the kitchen and one used for both serving in the dining room and for providing personal care. It was suggested that it would be easier to ensure staff changed their aprons if different coloured aprons were used for handling food and personal care. The deputy manager said she would implement this immediately. Staff said they always use protective clothing and agreed it would be better to use different colours. Staff said they have had training in infection control. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 21 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 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient and suitably trained staff employed at the home, ensuring that residents’ needs can be met. Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: The home has assessed their minimum staffing levels to be 7 care staff and 2 nurses during the day and 3 care staff and 1 nurse at night. In addition the home employs an administrator, cooks, kitchen assistants, a laundress, a handyman and cleaners. The home employs male and female staff and they are of varying ages and from differing ethnic backgrounds. Staff said there are normally enough staff on duty and they will try to cover any sudden absences. Any gaps on the rota are put in the diary for staff to take as extra shifts. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 22 There are just under half the care staff that have completed National Vocational Qualification level 2 or above and there are a number of staff currently working towards one of these qualifications. Staff confirmed they have either taken or are taking one of these qualifications. Staff files seen showed that the correct recruitment practices are followed, however one file for a long standing member of staff had a Criminal Records Bureau Check from when they had done a college placement at the home and had not had one done when starting to work as a member of staff. The administrator immediately arranged for one to be sent for. The manager said the home follows their equal opportunities policy in the recruitment of new staff. The deputy manager is responsible for coordinating the training and there was a notice in the residents’ newsletter stating that she had won the trainer of the year competition held in all of the providers’ homes. The manager showed the computer-training programme they use which requires staff to work through modules and complete tests at the end. Staff said they had received training in moving and handling, adult abuse awareness, fire safety, basic food hygiene, infection control and dementia awareness. A resident said, “The staff seem very well trained to me”. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable management systems in place for the smooth running of the home and to protect residents. Residents are at risk of being stuck in the lift. EVIDENCE: The manager was registered in December 1998 and is a Registered Mental Nurse. The manager said she had completed the Registered Managers Award and is waiting for verification. Staff said that the manager is approachable and supportive but will say if something is not right. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 24 A resident said, “I think the home is very well run”. The manager showed some new survey forms she was planning to distribute to residents and their relatives to complete for their views on the services provided. The manager said a survey was carried out last year, but the forms were not available to look at. The home will hold money for residents to pay for hairdressing, chiropody and other incidentals. Records seen showed a record is made of each transaction and signed and witnessed. Receipts are kept when available. A visitor was also seen paying some money into their relatives account. The manager said that all the required health and safety checks are carried out at the required frequency and there are service contracts in place for servicing all the equipment. Dates of tests were recorded in the Annual Quality Assurance Assessment showing they are regularly carried out. A sample of these were looked at and found to be correct. Whilst using the lift when looking round the home this became stuck and staff had to call for assistance. A member of staff said this was not the first time this has happened and the manager said the contractor had been called out previously. The manager said the contractor would be called out today to look at the problem. Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 3 X X X 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 2 X 3 X X 2 Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14(1)(a) Requirement Information collected as part of the assessment process for new residents must be available and assessments dated when completed. Care plans must clearly describe how resident needs are to be met and where a need is identified a care plan must be written for this. This will ensure that staff know how to meet residents’ needs. Resident’s cultural needs must be addressed, including through activities provided and diet. A record must be made of all complaints received The home must use a quality assurance system The lift must be in full working order. Timescale for action 01/09/07 2 OP7 15(1) 01/10/07 3 4 5 5 OP7 OP16 OP33 OP38 15(1) 22(1) 24(1)(a) 13(5) 01/10/07 01/09/07 01/09/07 30/07/07 Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kirkby Manor Care Home DS0000063843.V343862.R01.S.doc Version 5.2 Page 29 - 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!