Inspection on 20/06/05 for Kirkdale Nursing Home

This inspection was carried out on 20th June 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kirkdale Nursing Home 06/10/09

Kirkdale Nursing Home 11/05/09

Kirkdale Nursing Home 20/05/08

Kirkdale Nursing Home 04/06/07

Kirkdale Nursing Home 10/01/07

Kirkdale Nursing Home 04/05/06

Kirkdale Nursing Home 28/11/05

Kirkdale Nursing Home 29/09/04

Kirkdale Nursing Home 15/04/04

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

CARE HOMES FOR OLDER PEOPLE Kirkdale Nursing Home Radcliffe Crescent Teesdale Estate Thornaby Stockton-on-Tees TS17 6BS Lead Inspector Julia Connor Unannounced 20 June 2005 11:15 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. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kirkdale Nursing Home Address Radcliffe Crescent Teesdale Estate Thornaby Stockton-on-Tees TS17 6BS 01642 611199 01642 618899 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) Cleveland Alzheimers Residential Care Mrs Christine Robinson Care Home 38 Category(ies) of DE - Dementia (38) registration, with number of places Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th September 2004 Brief Description of the Service: Kirkdale is a care home providing nursing care for older people with mental health needs. It is a single storey purpose built home all bedrooms are for single occupancy; bedrooms are not en-suite. The bedrooms are a minimum of 10 sq.m. There are two dining rooms and several lounges. The home is on a bus route and close to the local town centre. Car parking facilities are provided. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection commenced at 11.15 am and concluded at 4.45 pm. One visitor and three members of staff were spoken to during the inspection. One visitor stated that he did not wish to wish to the Inspector as he had no complaints and he had spoken to her at the last inspection. Due to the nature of their mental health problems the Residents were unable to voice their opinions of the home. However, observation showed that the staff cared for the Residents with respect and courtesy. The Inspector was concerned when she was informed that new commodes would be purchased with money from fund raising. It is the responsibility of the Trustee’s to replace old and well-worn furniture, which includes the commode chairs. The Inspector was also told that money raised through fund raising events might be used to buy new crockery; again this is the responsibility of the Trustee’s. The home is currently advertising for a deputy manager. What the service does well: What has improved since the last inspection? There has been improvement in the recording within the Residents care documentation. Activities are now held on a regular basis to provide stimulation for the Residents. Supervision for the care assistants has commenced. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 Page 6 Decoration of Rosemary corridor has commenced. 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. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 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 Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 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 and 4 The Residents have their needs assessed prior to their admission to the home, however there was no evidence that the Resident or their family member had been involved in the assessment process. EVIDENCE: Four of the Residents care files were audited and all contained assessments carried out by professionals working outside of the home. Pre-admission assessments had been carried out by staff from the home prior to admission. However, there was no documentation in place to show that the Resident or their family member had been involved in the assessment that took place. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 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 and 8 The Residents nursing and personal care needs are not recorded fully in individual care plans. Resident’s health care needs are met. EVIDENCE: Four Residents care plans were audited. Although the recording in the files had improved there is still some work to do. When a care plan is formulated the actions that are required are not always taken. For example one plan stated that all of the food that the Resident had eaten over the day would be recorded; this recording stopped on 2/6/2005 but staff had not recorded if they no longer needed to monitor the amount food the Resident had taken so it appeared that they had forgotten to make an entry regarding the Residents food consumption. Care plans relating to wound care should be more specific, e.g. the size of the wound should be measured so that there is evidence that it is improving or not. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 Page 10 There was documentation in the notes audited that did not have the name of The nursing the nurse completing the documentation nor a signature. observations carried out on admission had not been completed yet the Resident had been in the home since May 2005. There was no evidence in any of the notes that the Residents next of kin had been involved in the assessment or review process for their relatives care. Doctors, District Nurses, Chiropodists etc are requested to visit the Resident as and when necessary. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 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) 12 and 15 Meaningful activities are provided for the Residents. Residents receive a wholesome and well balanced diet but not in pleasing surroundings. EVIDENCE: Meaningful activities are now offered to the Residents and the Inspector was showed photographs of such activities; family members are encouraged to participate in the activities. There were photographs of the Residents enjoying baking, building with lego as well as singing and dancing. On the day of the inspection the lunch served to the Residents was spaghetti bolognaise followed by ice cream, which the Residents appeared to be enjoying. The alternative was fish cakes and hash browns. The smaller dining room seemed very crowded. There was staff available in both dining rooms to offer assistance where necessary; there were also family members helping to feed their relative. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 Page 12 An audit of the kitchen showed that the cook made her own cakes, both large and small as well as homemade rice pudding. A visitor to the home stated that her husband enjoyed the food that he was given; she herself had never eaten at the home. Melamine crockery is used at the home, the mugs which were ready to be used to give the Residents their cup of tea were badly stained, when this was discussed with the Manager she stated that they were ready to be replaced from funds raised by family members and staff. The carpets in both dining rooms require a deep clean and depending on the result of the clean may need replacing. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 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 standard(s) 16 The appropriate policies and procedures are in place for the investigation of a complaint and the staff are aware of the action to take should a complaint be made. EVIDENCE: There have been no complaints regarding the home since the last inspection in September 2004 There is a policy and procedure for staff to follow to ensure that the appropriate action is taken if a complaint is made. The complaint policy still refers to the National Care Standards Commission; this should be replaced with the Commission for Social Care Inspection. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 23 and 24 There are areas within the home that are not well maintained. furniture that needs replacing. There is EVIDENCE: There are lounge chairs that need replacing due to general wear and tear. Recliner chairs have been bought for some Residents by their families. Some of the money raised by family members and staff has been used to buy more recliner chairs. There are commode chairs that also need replacing due to general wear and tear. The Manager informed the Inspector that the commodes would be replaced with money from the funds raised by families and staff. It is the responsibility of the providers to provide furniture for the Residents. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 Page 15 Sixteen-bedroom carpets need replacing due to them being stained to some degree. One Residents family member replaced the bedroom carpet himself. The carpets in both Rosemary and Lavender corridors require replacing, as does the corridor outside of the dining rooms. The dark bedroom furniture needs replacing, there are drawers that are loose and beading is missing from a wardrobe. There are dents and scuff marks on this furniture. The majority of the bedrooms have been personalised with photographs and ornaments by the Residents family members. The garden is well maintained and was being used by a Residents and his wife on the day of the inspection. However, the paving at the front of the entrance is still cordoned off due to the paving being uneven. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 Page 16 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) 28 Staff are being trained to NVQ level 2 that should ensure that they can meet the Residents needs. EVIDENCE: 40 of the care assistants have their NVQ Level 2 in care. Five members of staff are currently working towards their NVQ Level 3 and a further four members of staff are currently working towards their NVQ Level 2. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 Page 17 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) 31, 32, 33 and 36 The Manager of the home is fit to be in charge. There is no effective quality assurance and quality monitoring system available. Care staff receive formal supervision. EVIDENCE: The Manager has the required nursing and management qualification to ensure that the needs of the Residents are fully met. The staff spoke highly of the Manager, as did the visitor who spoke to the Inspector. There was no quality assurance documentation available for the Inspector; the Manager stated that she thought that the General Manager had it. The quality assurance and quality monitoring audits should be made available to the Residents and their representatives as well as other interested parties, including the Commission for Social Care Inspection. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 Page 18 There was evidence in the care staff’s personnel files that supervision now takes place and the care assistants who spoke to the Inspector confirmed this. However, formal supervision does not take place for the qualified staff. Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 Page 19 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 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 2 x x 3 2 x x STAFFING Standard No Score 27 x 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 2 x x 2 x x Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 Page 20 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 3&7 Regulation 15 Requirement The plan of care must be drawn up with the involvement of the Service User, recorded in a style accessible to the Service User and signed by the Service User whenever able and/or their representative. THIS IS OUTSTANDING SINCE THE SEPTEMBER 2004 INSPECTION. In order to demonstrate the home’s capacity to meet the assessed needs of the Service User, the registered person must ensure that there is sufficient information about the Service User in the nursing documentation. THIS IS OUTSTANDING SINCE THE SEPTEMBER 2004 INSPECTION. The registered person must make safe the entrance to the home by ensuring the paving slabs are even thus avoiding unnecessary risks to the health and safety of Service Users. THIS IS OUTSTANDING SINCE THE SEPTEMBER 2004 INSPECTION. The registered person must provide adequate furniture, bedding and other furnishings B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Timescale for action 31/10/05 2. 7 15 31/10/05 3. 19 & 38 13 30/9/05 4. 19 & 20 16 31/10/05 Kirkdale Nursing Home Version 1.30 Page 21 5. 19 23 6. 20 & 23 16 7. 33 24 suitable to the needs of the Residents. The registered person must ensure that all parts of the home are kept clean and reasonably decorated. The registered person must provide adequate furniture, bedding and other furnishings suitable to the needs of the Residents. The registered person must establish and maintain a quality audit system. 31/10/05 31/10/05 31/10/05 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 28 Good Practice Recommendations The registered person should make arrangements for a minimum of 50 of care staff to be qualified to NVQ Level 2 or equivalent by 2005 Kirkdale Nursing Home B51-B01 S182 Kirkdale V234302 200605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Unit B, Advance St Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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