Inspection on 02/03/07 for Kirkhill

This inspection was carried out on 2nd March 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

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

CARE HOMES FOR OLDER PEOPLE Kirkhill 127 Low Edges Road Sheffield S8 7LE Lead Inspector Ian Hall Key Unannounced Inspection 2nd March 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 Kirkhill DS0000067347.V319795.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. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirkhill Address 127 Low Edges Road Sheffield S8 7LE 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) 0114 2373211 0114 2377146 Sheffield Care Trust Mrs Victoria Klymczuk Care Home 29 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (29) of places Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Where additional services are provided e.g. day care, outreach, escort duty, staffing for this must be over and above that required for the registered service. 14/03/06 Date of last inspection Brief Description of the Service: Kirkhill is a two-storey purpose built care home. It provides personal care for service users with mental health problems. The home is registered for 29 places and divided into 2 units. The home is situated in the Low Edges area that is approximately five miles from Sheffield City centre. Each unit is self-contained with bedroom, bathing, toilet, dining and lounge areas. Shared communal areas are provided on the ground floor providing opportunities for service users from both units to make friends and socialise. First floor accommodation is accessed by means of a passenger lift and staircases. The home has well-maintained, safe useable garden areas and car parking facilities. Many of the service users lived locally and maintain contact with the wider community. The home makes use of both the local amenities and events. The home does become busy with visits from family and friends of service users. A mini-bus is provided for the use of service users. Additionally Kirkhill provides both a 10 place day-care unit and the Brooklees Day Hospital (an NHS Sheffield Community Trust) facilities for service users with mental health problems. These areas are accessed via the main entrance but do not impact upon the lives of service users who reside at Kirkhill. These services are neither registered nor inspected by the Commission for Social Care Inspection (CSCI). Information gained on the 2nd March 2007 indicated the current fees range from £340.00 for personal care additional charges are made for hairdressing and chiropody. These fee charges only applied at the time of inspection, more up to date information may be obtained from the manager of the home. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over five and a half hours on the 2nd March 2007. The emphasis of the inspection was placed upon meeting service users and the staff team. The inspector toured the site to observe the redecoration and refurbishment that had taken place since the last inspection. The inspector case tracked 3 service user files and associated records. What the service does well: What has improved since the last inspection? What they could do better: Continue to update and redecorate areas of the home that appeared tired and worn. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 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 Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had written information that described Kirkhill for potential service users and their relatives. Assessments of service users had been completed prior to them moving into the home, they are required to ensure that the home and staff were able to meet their needs. The staff team had received a range of training to ensure that they understood the needs of service users. EVIDENCE: The homes statement of purpose and service user guide provided service users with clear information that detailed the facilities, care and services available at the home. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 9 The three case records examined had copies of pre-admission service user care assessments. These provided a detailed picture of each service user and their physical, psychological and social needs. These are required to ensure that the home is suitably equipped and able to meet prospective service users care needs. The assessment had been used to compile the initial care plan. One of the service users spoken with was able to confirm that she had been involved in the choice of care home, and had taken the opportunity to visit before making a decision to live at. Case files inspected contained a copy of a contract/statement of terms and conditions. These detailed the fees, including any extra charges, and the facilities and standard of care service users can expect to receive. Intermediate Care is not provided at Kirkhill. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 10 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users appeared well cared for. There were detailed assessments and care plans in place to identify what help and support service users needed. The medication system was well managed with policies and procedures in place to guide staff and protect service users. Service users were treated with respect and their right to privacy upheld. EVIDENCE: Seven service users were spoken with. They said that they were able to see their doctor, optician or chiropodist when they needed to. They said the staff to be very kind and helpful. Detailed records of these visits and their outcome had been made following each visit. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 11 Care records of three service users were inspected. A range of recognised assessment documents had been used to measure service user needs. These included mobility, mental ability, state of nutrition, and areas of risk such as falls. These provided a baseline for staff to assess service user progress or increasing level of need. This enabled staff to plan the help and support service users needed. Reassessment of service users and their changed needs were appropriately recorded. Daily records were made of the care and activities provided for each service user. Details of service users religious and cultural needs and the gender of staff that they wished to support them with their personal care were clearly identified. One of the service users spoken with was able to confirm that they had helped draw up their care plan and that they could have access to them whenever they wanted. Records were kept of medication received, and disposed of. Medication was securely stored and administered according to the doctor’s instructions. Records of medicines given were completed in full and correctly. Staff had received additional training for the administration of medicines, they were observed assisting service users to take their medication safely. Lockable facilities were provided within service users bedrooms for service users who were able and wished to retain control of their own medication. The manager confirmed that the supplying chemist provided guidance and support for staff to ensure service user safety. Policies and procedures to inform staff and protect service users taking medications were current and available for inspection. Service users said that the staff respected their privacy. The inspector observed staff knocking on bedroom doors and waiting to be invited in before entering. Service user meetings had been held on a regular basis and minutes of these meetings were available within the home. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 12 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users said that suitable activities provided at the home to keep them stimulated. Visits from relatives and friends were encouraged ensuring that service users kept in touch with people who were important to them. Service users said the food was good and they were offered choice; special dietary needs and preferences were recorded in the individual care plans. EVIDENCE: Service users confirmed that they were able to go to bed and rise as they chose. Breakfast was being served throughout the morning to service users who had chosen to stay in bed longer. A number of service users confirmed that they left the home to shop locally or use community facilities. Staff had accompanied service users to places of local Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 13 interest weather permitting. Service users were observed to be reading, listening to music and watching television. Staff regularly organised activities that stimulated service users and encouraged social interaction. These included bingo and celebrations of national festivities. The kitchen was closed for a two-week period for refurbishment at the time of inspection. Suitable alternative arrangements had been made to ensure the meals provided continued to be of a high standard. The breakfast and lunch offered to service users both appeared and smelled appetising. It was served hot, was well presented with a good choice being offered. Several service users who required them had special diets provided for health reasons. Staff were observed to encourage and assist service users with meals as needed. Mealtimes were unhurried; meal size was provided as service user chose with extra portions available as required. The menu was displayed in each dining room there were records of service users choice of meal or amount of diet consumed. Service users dietary likes and dislikes were known to staff to assist service users to exercise choice. The dietician had helped to compile the menu. Service users weights were recorded regularly to monitor their health and wellbeing. Service users and staff confirmed that snacks and drinks were available at any time. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a complaints procedure to allow service users to raise any concerns. The staff had been trained in the recognition and reporting of abuse and relevant checks were made prior to them starting work, this reduced the risk of harm to vulnerable service users. EVIDENCE: One complainant had brought concerns to the manager’s attention, two elements of their concerns that were investigated were acknowledged to be founded, action had been promptly taken to remedy the deficits. They were investigated, recorded and actioned promptly within the home’s policy and procedure. The complaints procedure was available for service users, their relatives and staff. Staff had been provided with training in adult protection procedures to ensure service users were safe, and to inform staff what to do if an allegation was made. The inspector’s discussions with staff demonstrated that they felt confident and able to respond to concerns or complaints competently. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 19 and 26. The home was clean, tidy and well maintained ensuring that service users live in pleasant and safe surroundings. The bedrooms were comfortable, clean, homely and reflected personal choice. EVIDENCE: Service users said the home was always clean, warm, well lit and there was always enough hot water. The home is divided into two distinct living areas. Soft furnishings, pictures, flowers and ornaments were used throughout the home to provide a homely domestic setting. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 16 Service users said they had a choice of colours for their redecorated bedrooms. The bedrooms had been provided with matching curtains, bedding and soft furnishings. They had personalised their rooms with a variety of items of their choice including photographs and other mementoes. Bedrooms were lockable with keys available for service users who wished to exercise their choice and lock their own door. Several service users chose to spend their time in their own bedroom. There is level access throughout the home with handrails provided to assist service users to maintain their independence and mobility. A passenger lift was provided in addition to the staircases to enable service users to access the first floor bedroom area. Toilets were easily accessible as they were close to both lounge and dining areas. Adapted toilets were available for service users with physical disabilities. The toilets were equipped with door locks promote service user privacy and independence. There was an adequate number of baths, assisted bathing facilities were provided in convenient locations for service users. Staff had provided homely features within a number of toilet and bathroom areas to provide a warm and welcoming environment. Designated smoking areas had been provided for service users who wished to smoke. Appropriate seating has been provided in the secure garden for service users wishing to sit outside whenever the weather permitted. Service users that use this area could feel safe as they could easily observe and be observed by staff. The Kitchen was closed for upgrading and refurbishment on the day of inspection. This had been undertaken following consultation with the Environmental Health Officer. Clinical waste was properly managed and stored. Staff confirmed that they were provided with protective clothing if they needed it and that equipment was in working order, being serviced as required. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 27, 28, 29 and 30. Adequate numbers of staff were deployed to meet service user’s needs. Staff had received statutory training to help them meet the needs of service users. Checks had been made on staff to reduce the risks to vulnerable people. EVIDENCE: Sufficient staff were available to meet service users care needs. Additional staff were on duty to undertake catering, housekeeping and laundry tasks. Staff confirmed that they were well supported in their work with a senior member of staff always being on duty. The staff files examined confirmed that CRB checks and correct staff recruitment policy and procedures had been followed in each of the three files selected for inspection. The staff training and development plan was examined and was seen to identify staff training needs, courses completed and courses being undertaken. Staff spoken with confirmed they had undertaken statutory training and updates e.g. moving and handling, fire prevention. They were involved in Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 18 national vocational qualification training and medication administration training. The numbers of staff trained to level 2 NVQ in care exceeded the minimum 50 required by The National Care Standards Act 2000 and the associated Regulations. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 31, 33, 35 and 38. Staff said the manager was supportive and approachable and there was a wellestablished system of professional supervision. Service users were involved in making decisions about their care and had control over issues that affected their lives. Checks had been made on the major systems in the home such as fire and gas installations to ensure the home was safe for service users. Fire training had been provided for staff to reduce the risk to service users in an emergency. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager, a trained nurse had achieved the registered managers award and NVQ4. The service users and staff spoken with said the manager was approachable, very professional and they had complete confidence in her. The manager had a job description that clearly defines her roles and responsibilities and staff were aware of her role. The homes management employed a range of methodologies to measure service users satisfaction with the care and services provided. This included the Sheffield Community Trust (SCT) self-assessment quality assurance system this was audited by the service director. Results of the recently conducted surveys had been analysed and comments used to further develop the service. Regular service user and staff meetings are held with minutes being kept that were available for inspection. There are monthly monitoring visits made to the home by the service director who submits detailed written reports of the monitoring visits to the SCT and the Commission for Social Care Inspection (CSCI). All staff had received management supervision, this had taken place at regular monthly intervals; this is required to fully ensure individual staff development and monitoring care practices. Staff had received training on moving and handling, first aid, fire prevention, food safety and infection control. This ensured staff were prepared for their roles and responsibilities to meet service users needs and maintain their safety. The manager handles money on behalf of some service users, account sheets were kept, receipts were available for all transactions, and all transactions were witnessed by a second individual. Records were up to date and well ordered to ensure the best interest of service users. The homes policies and procedures met the required standards. Statutory servicing and checks of equipment were complete. Health and Safety at Work risk assessments had been undertaken and reviewed regularly. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 21 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 3 8 3 9 3 10 3 11 3 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 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 3 X 3 X X 3 Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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 OP19 Good Practice Recommendations Continue to update and redecorate areas of the home that appeared tired and worn. Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Kirkhill DS0000067347.V319795.R01.S.doc Version 5.2 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. 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