Inspection on 04/10/05 for Kirkby Manor Care Home

This inspection was carried out on 4th October 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 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 Keeling Unannounced Inspection 4th October 2005 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.V254578.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. Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 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 723724 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.V254578.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within category DE/E Date of last inspection 18th August 2005 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. Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over a 5.5 hour period and involved one inspector. The main method of inspection was case note tracking, this is a method of selecting service users within the home and discussing with them their expectations and experiences of living within the home environment. The case tracking method also analyses the records of the service users to ascertain if the service users identified needs are being addressed appropriately within the care home setting and that their safety and well being is being maintained. On this occasion two residents notes were case tracked. Also as part of the case tracking process, staff within the home were informally interviewed to further evidence the quality of care afforded to the service users. At the time of the inspection a total 39 residents were accommodated at Kirkby Manor. The manager and the care staff within the home are committed to providing a high standard of care to the residents. The manager within the unit was very helpful and cooperative thus ensuring that the inspection method progressed in a professional, efficient and effective manner. What the service does well: Informal discussion with two residents established that the care provided within Kirkby Manor is agreeable to them. Service users were particularly satisfied with the quality of food provided within the home. Services users stated that the care staff within the home are very friendly and respectful at all times. The inspector witnessed several interactions between staff and service users and indeed it was evident that staff respected service users wishes. Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 DS0000063843.V254578.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 Kirkby Manor Care Home DS0000063843.V254578.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): 3. 6. Service users needs are assessed prior to admission. Kirkby Manor does not provide an intermediate care facility. EVIDENCE: Service users or representatives of the service users are given the opportunity to assess the quality and suitability of the home prior to admission. Information is provided to the service user or their representatives in relation to the services and facilities provided within the home. A leaflet is available which clearly identifies facilities and resources available at Kirkby Manor. The case tracking procedure revealed that social services departments, prior to admission, had provided thorough assessments, which explicitly identified the needs of service users. Kirkby Manor Care Home DS0000063843.V254578.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): 7.8.9.10 It was evident that the identified needs of the case tracked service users had not been fully addressed and care plans had not been formulated by the nursing staff responsible for this process. As such the inspector could not establish if service users identified needs were being met appropriately within the home and that the safety of the service users is being assured No service users within Kirkby Manor are responsible for the administration of their own medication. Although an assessment of the service users capabilities in relation to self-administration of medication was not evidenced. Service users and service users relatives stated that they are treated with respect and dignity and that privacy is always maintained within Kirkby Manor. EVIDENCE: The case tracking process revealed significant shortfalls in the evaluation and care planning process at Kirkby Manor. At the time of the inspection the Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 Page 10 manager together with the qualified nursing staff were in the process of transferring existing information and care plans into the new documentation format provided by the new owners. The documentation of two service users was case tracked. Of the two case tracked care plans, one service users care plan did not contain any evaluations or care plans whatsoever although a detailed identification of needs had been provided by social services department prior to admission. This represents a significant risk to the service users and staff employed within Kirkby Manor. An immediate requirement was initiated to address this shortfall. The second case tracked notes revealed significant shortfalls in the evaluation and care planning process. Documentation was evident from social services, which specifically identified the needs of the service user, and some evaluation and cared planning had taken place within Kirkby Manor. On many occasions, the assessor had not signed or dated the evaluation documentation or the care plans. Evaluations, which should be performed on a monthly basis had not, in many instances been performed, thus any changing needs of the service users could not be identified or acted upon by staff within Kirkby Manor. At the time of the inspection, service users were very clean and presentable. Service users spoken with were positive about the way staff spoke to them stating that staff knocked on the resident’s bedroom door before entering. Service user stated that the staff respected their privacy and dignity when bathing or performing personal care. The inspector witnessed staff addressing the service users in a very pleasant and respectful manner and it was evident that the service users were very comfortable and happy within the home environment and the staff employed within the home. At the time of the inspection a service users relative was spoken with who confirmed that he has a great deal of confidence in the abilities of the staff employed within Kirkby Manor. On no occasion had he witnessed any incidents that had given him cause for concern in relation to the care afforded to the residents within Kirkby Manor. Although no service users within Kirkby Manor are responsible for selfadministration of medication it could not be established that a thorough assessment in relation to the service users abilities in self-administration of medication had taken place. A recommendation in relation to this matter will be formulated. Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 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 the following standard(s): 12.13.14.15 Service users are encouraged to maintain contact with their family and friends. Service users are always encouraged to exercise personal control and choice over their lives. Service users are provided with a wholesome and appetising diet but a choice of a main course is not evident on the daily menus. EVIDENCE: Following a discussion with a service users relative it was evident that no restrictions are placed on the family or friends of the service users in relation to visiting times. It was established that the management and staff within the home always made visitors very welcome and appreciated the importance of service users maintaining effectual contact with people beyond the immediate environment of the home. Service users interviewed were very well presented and were very happy in the home environment. All service users were dressed appropriately for the season in their own clothes and footwear thus promoting personal choice, respect and dignity. Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 Page 12 A very enthusiastic activities coordinator has been recently appointed who will be working three hours per day over five days per week. The activities coordinator has been given the opportunity to access a six months, self directed, educational course appertaining to the responsibilities of an activities coordinator. A trained nurse, to facilitate the educational process, will support the activities coordinator within Kirkby Manor. Currently service users enjoy varied social activities within the home such as dominos, painting and colouring, movement to music, and trips to Kirkby town centre. A minibus is available and it was confirmed that the residents can access day trips to local parks, public houses and a small animal farm, which the service users particularly enjoy. Holy communion is available to service users within the home. It was established that at a later date the activities coordinator will maintain an activities log to demonstrate service user preference in relation to social activities, thus ensuring the service users can exercise a choice in relation to which social activities they attend. Service users stated that the food in the home is “first-rate”. It was evidenced that a varied selection of meals are available throughout the day. A daily menu board is on order and will be installed as soon as possible so that the service users have the opportunity to choose from the variety of meals available. It was established that an effective system is in place to provide service user with specific meals and as such service users with diabetes or swallowing difficulties can be catered for effectively. Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 Page 13 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 Service users and their relatives and friends are confident that their complaints are listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Kirkby Manor had no outstanding complaints at the time of the inspection and has not received any complaints since the last inspection. It was evident through discussions with staff members that they felt confident in their knowledge of the complaints procedure and how the procedure should be followed in the event of a complaint. Following a discussion with a service users relative it was evident the service users relative would feel confident and comfortable to express any concerns or complaints to the care staff or management within the home. It was evidenced that all members of staff have received a comprehensive induction programme over a three-week period and a full and varied ongoing “in house” educational programme is in place. Staff personnel files evidenced training courses attended that specifically relate to protecting the vulnerable adult from abuse. The courses pertinent to the protection of the vulnerable adult include abuse awareness training, dementia care, fire training, moving and handling, first aid, continence care, care planning and implementation. Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 Page 14 Pre employment screens are performed for all new members of staff, which satisfies the legal requirements identified in the Care Standards Act 2000. Documentary evidence in relation to re-employment checks were satisfactory. The homes policies and procedures did not highlight the need to have two suitable references and a Criminal Record Bureau (CRB) or Protection of Venerable Adults (POVA) (part 1) before any individual is employed within the home, as such an immediate requirement will be made to address this shortfall. Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 Page 15 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. 26 The standard of cleanliness throughout the home is good, and all areas within the home smelt fresh and pleasant. The overall internal appearance of Kirkby Manor is somewhat dated and will benefit from the intended complete refurbishment planned by the new owners. EVIDENCE: The inspection process allowed for the examination of service users bedrooms and communal living areas. All areas within the home were clean, homely, smelt fresh, but were not of a high decorative condition. The new owners of Kirkby Manor have purchased an industrial carpet cleaner which is being used throughout the home effectively. It was evident that residents had many personal possessions in their bedrooms such as family pictures and ornaments, thus promoting a homely, pleasant environment for the service users. Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 Page 16 To promote safety for the residents all radiators are enclosed and the windows have opening restrictors in place. Within the communal bathroom area, cleaning substances and toiletries were evident. Given the client group cared for within the home the potential for ingestion by the residents is significant and as such a requirement will be made to ensure that the aforementioned substances are stored appropriately. Several mobility aids and a television were being stored in the upstairs sluice area which could present as a potential risk for the service users. Although it was established that the sluicing room was not in use, the area should be locked to prevent service user entry thus ensuring service users safety. To protect residents and promote the principles of infection control a “dissolvable red bag” laundry collection and washing service is in operation when required. The laundry areas are well equipped with industrial washers and tumble dryers. It was a requirement from a previous inspection that appropriate Control of Substances Hazardous to Health (COSHH) documentation be displayed within the laundry area and this requirement was being met at the time of the inspection. Individual laundry boxes are utilised to minimise the risk of garments being delivered back to the wrong service users thus promoting the principles of respect and dignity afforded to the service users. It was evident that all the hot water outlets in the service users rooms are fitted with appropriate thermostatic valves to minimise to risk of scalds and that water temperatures are recorded appropriately. All the service users bedrooms and communal areas viewed during the inspection were clean, homely but not particularly well decorated. It is the intention of the new owners to totally refurbish Kirkby Manor in the near future and a programme of refurbishment is currently being formulated to address the decorative shortfalls. Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 Page 17 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): 28. 29. 30 Kirkby Manors recruitment policy does not ensure that residents are protected from abuse. EVIDENCE: On examination of Kirkby Manors recruitment policy, shortfalls were identified. Specifically the policy did not highlight the need for two satisfactory references, or a Criminal Records Bureau (CRB) check or a Protection of Vulnerable Adults (POVA) check. Although it was evident that this documentation had been sought prior to employment, these requirements must be stated in the recruitment policy within the home. It was established that the recruitment policy within the home remained from the previous owner. The new owners, Hallmark Healthcare, will provide Kirkby Manor with their recruitment policy at the earliest opportunity and that the policy will be forwarded to the Commission for Social Care Inspection as soon as possible for verification. Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 Page 18 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): 31. 35. 38. It was evident that the manager at Kirkby Manor is professional, fit to be in charge, of good character and is able to discharge her responsibilities fully. EVIDENCE: The manager of Kirkby Manor has ensured that staff within the home receive a comprehensive annual training programme. A previous inspection highlighted the need for all qualified nursing staff to receive first aid training; this requirement has now been satisfied. On a weekly basis the manager now monitors drug administration records within the home to ensure that shortfalls in relation to the recording of medication administration, identified at a previous inspection are not repeated. A requirement from a previous inspection highlighted the needs to monitor the temperature of the medication fridge and the treatment room where Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 Page 19 medication and dressings are stored, it was evidenced that this procedure is now in place and be managed effectively. The manager performs regular inspections of all areas within the home to ensure that all areas are appropriate for the provision of health care for the service user group. Service users, relatives and staff spoken with voiced a great deal of respect for the manager at Kirkby Manor Care Home and were very pleased with her management style and performance. Service users “petty cash” was stored individually within the care homes safe and an effective system is in place to record all incoming and outgoing money. It was established that service users money is also kept in a joint account and that proper provision for the identification and addition of any interest from service users monies could not be identified, this was particularly important as some service users had substantial amounts of money held within the joint account. In addressing this shortfall an immediate requirement was made. Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 Page 20 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 3 x X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 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 3 17 3 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x X X 2 X X 3 Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 Page 21 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 7 Regulation 15 Requirement The registered provider must ensure that service users care plans must be in sufficient detail to provide clear guidance to staff on the actions to be taken to meet the health and welfare needs of the service users. The registered provider must ensure that all service users plan of care are kept under review. The registered provider must ensure that within the communal bathroom area, cleaning substances and toiletries were evident. Given the client group cared for within the home the potential for ingestion by the residents is significant. The registered provider must ensure that the out of use upstairs sluicing area will be locked at all times to prevent service user entry. The registered person must ensure that a robust recruitment process is in place to guarantee the safety of service users. The registered person shall not pay money belonging to any DS0000063843.V254578.R01.S.doc Timescale for action 31/10/05 2 3 8 19 15 (2) 13 31/10/05 31/10/05 4 19 13 03/11/05 5 29 19 31/10/05 6 35 20 (1) 31/10/05 Kirkby Manor Care Home Version 5.0 Page 22 service user into a bank account unless the account is in the name of the service user, to which the money belongs. 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 9 Good Practice Recommendations All service users should be evaluated in relation the their ability to self medicate thus promoting the principles of choice, respect and dignity for the service users. Kirkby Manor Care Home DS0000063843.V254578.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park 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 DS0000063843.V254578.R01.S.doc Version 5.0 Page 24 - 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!