Inspection on 30/09/05 for Kirkland House

This inspection was carried out on 30th September 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 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

Kirkland House 06/02/07

Kirkland House 23/02/06

Kirkland House 14/12/04

Kirkland House 13/07/04

Kirkland House 17/03/04

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Larchfield Manor

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

CARE HOMES FOR OLDER PEOPLE Kirkland House Queensway Yeadon Leeds LS19 7RD Lead Inspector Valerie Francis Unannounced 30 September 2005 th 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. Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kirkland House Address Queensway Yeadon Leeds LS19 7RD 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) 01943 876392 Leeds City Council Mrs Linda Cox Care home 31 Category(ies) of Old age (31) registration, with number of places Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: NO Date of last inspection 14/12/05 Brief Description of the Service: Kirkland House is a large building situated in a residential area of Guisley. The location offers a good bus service to Yeadon and access to the Guisley shopping Centre. The building is a large detached purpose built care home for older people.which is owned and managed by Leeds City Council as a Social Care Home.Prior to the Care Standards Act, care homes owned by local authorities were exempt from registration. Kirkland House accommodates 31 older people on two floors. There are 31 single bedrooms and six of which previously shared rooms.The first floor can be reached via a passenger lift. Toilets are strategically placed throughout the building, giving easy access to service users. There are four baths and a level access shower, which provides choice and support at the time of bathing. There is satisfactory parking at the front of the home. Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Regulated care homes have a minimum of two inspections a year; these may be announced or unannounced visits. The last inspection was announced and took place on the 14th December 2004. There have been no further visits until this unannounced inspection, which was carried out by one inspector, which started at 9.am and ended at 3.45 pm. The people who live in the home use the term ‘residents’ therefore this is the term that will be used throughout this report. The registered manager was not on duty on the day of the inspection and the care officer in charge of each shifts facilitated in the inspection process. The inspectors examined resident’s records, and other records that were available. Some areas of the home were seen. These included the lounge and dining rooms. Care staff were observed carrying out their work, and discussions were held during the day with members of staff, residents, and their visitors. Residents and their relatives made positive comments about the standard of their care and the staff team on the day of the inspection. What the service does well: What has improved since the last inspection? The Information available to prospective residents and others provide them with information to help them make an informed choice. All staff have received Adult Protection Awareness training. Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 Page 6 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. Kirkland House J52 S33261 Kirkland House V233676 250805 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 Kirkland House J52 S33261 Kirkland House V233676 250805 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) 1 & 3 Prospective residents and their carers/relatives are able to make a decision about the suitability of the home from the home’s information pack and visits to the home. Despite assessment information provided by social workers, the home could not demonstrate that it could meet the assessed needs of prospective residents. EVIDENCE: Staff members said that each prospective resident and/or their relatives were given an information pack, which contained copies of the home statement of purpose and other information about the home. Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 Page 9 The care records of three residents were examined, including a recent admission to the home. There was a social work assessment in two of the files; however, there was no evidence in three of the files seen to show how the home had assessed the needs of these residents. The inspector was shown a fourth care file which had evidence that an assessment had been carried out by the home, however, none of the three files that was fully examined had any evidence that assessments have been carried out by the home. The manager must ensure that assessment process is carried out for all potential resident to make sure that needs can be met at the home. Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 &10 Staff members are provided with details from core assessment to carry out care task to care for residents. EVIDENCE: Three residents’ life style plan (care plans) were inspected all of which included information on daily living. Most of the information was taken from core assessments and there was no evidence that an assessment had been carried out by the home, which may result in the care needs of residents being missed. Although regular reviews had been carried out there was no date of when the review had taken place. The inspector found that life style plans had good information, however, a care plan must be in place to provide staff with enough information and include an action plan that details how these identified needs would be met. Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 Page 11 The information seen on the monthly review had no details of some of the resident’s assessed needs and gaps were noted, which may result in unmet needs for residents at the home. There were formats seen to record risk assessments, however, the format did not allow staff to record the action to be taken to minimise risk. There was no evidence to show that moving and handling risk assessments had been carried out. The fall management information sheet only recorded the date and incident about the fall but there were no information on the risk factors or the action taken to minimise the risk of falls in the home. Each person had a nutritional risk assessment that was completed if a risk had been identified, however, the risk could only be identified if the assessment was carried out. Residents and their visitors made positive comments about staff and the way they treated residents, which was said to be kind and friendly. The environment was described as homely and there was a good atmosphere. It was clearly noted during the inspection that the privacy and rights of the people living at the home was respected. All personal care is carried out in the person’s room. There are no shared rooms. Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 Social recreational activities match the expectations and preferences of residents. EVIDENCE: Residents had the opportunity to take part in activities to suit them either at the home in house or in the community. Individual staff member’s skills were used to make sure that each resident’s social recreational needs were being met. The are two weekly outings arranged at the request of residents and the bar is opened during the evenings. The ‘TUC Shop’ is opened to residents three time a week and the hairdresser visits the home weekly, which is seen by resident’s as a social event and gives residents who do not go out the opportunity to speak to someone other than staff. At the time of the inspection children and their teachers from the local primary school visited the home with gifts of fruits and vegetable from the school Harvest festival. Throughout the inspection residents were seen to be engaged in their own activities either as a group or individually, for example, playing cards, knitting jigsaw, or reading. A number of visitors were also seen visiting the home Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 Page 13 during this time. There was a sense of activities with visitors coming and going through out the inspection. Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Residents and their visitors are confident that their complaints would be taken seriously. Systems are in place to make sure residents are protected from abuse. EVIDENCE: The complaints procedure is displayed on the notice board in the entrance to the building. A copy of the social services complaint and compliment procedure is given to all prospective residents and their relatives and others. A record is kept of all complaints and compliments. Incidents are recorded on an incident log copy of which is sent to line management of the home. During discussions with residents and their relatives they said they were confident that their complaint would be taken seriously and they knew what to do and who to speak to. All staff members have had adult protection awareness training and are confident what to do if an alleged abuse occurred. Adult protection policy and procedure and associated information are readily available to staff, in the office. Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 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 standard(s) 19 & 26. Residents have access to a homely and safe environment. Which is kept clean and to a good standard. EVIDENCE: The location of the home offered residents access to local shops, including Yeadon’s shopping centre. Residents also had access to local recreational facilities that were used by residents and supported by staff. The home’s grounds were tidy for the time of the year and it was apparent that during the summer a lot of work had been put into the garden and the home had entered the Local Authority garden competition. There were on going replacement and refurbishment activity in the home to create a safe environment for residents. There was evidence to show that staff and residents worked together to keep the building looking homely. From discussions with domestic staff and from Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 Page 16 observation made, it was noted that there was a sense of pride in the standard of cleanliness and there was no malodour detected throughout the home. All staff have had moving and handling training and some have had infection control training. At the time of the inspection several staff were completing the course. Risk assessments have been carried out on the building including on going health and safety checks. There is a monthly safety survey check with a report of the findings, which are sent to head office. In general the inspector found the building to be cleaned to a high standard. Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 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 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) 27 & 30. Night staffing levels are not appropriate to meet the needs of the residents and the layout of the building. All new staff members are provided with training to ensure that they are competent to carry out their duties and deliver a good standard of care. EVIDENCE: At the time of this inspection, staffing levels during the day appeared to be adequate, however, the staffing levels at night were not enough to meet the needs of the residents living at the home. The layout of the building, created a risk to residents at night with two waking night staff on duty. There is an on call arrangement in place at the home and staff from adult services throughout the city have access to the person on call. The home at the time of this inspection had several staff vacancies. These were 90 hours of care during the day, 10 hours during the night and 25 domestic hours. An advert for 35 hours care assistant post had been advertised. There was one (35 hours) member of staff on long term sick. These vacant posts were covered by staff doing over time to make sure that residents have the same people at all times working with them. All new staff received induction training and going training and there is an annual training plan in place for all staff. During discussions with staff, they said that they have had quite a lot of training, including on going NVQ training Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 Page 18 and any specialist training that is needed to meet the care needs of the people living at the home. Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 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 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) 33 & 36 There was no information available of the outcome of quality survey carried. Staff are appropriately supervised. EVIDENCE: There were systems in place at the home to help residents and other people to have a say in the running of the home. There were quarterly meetings held for relatives to give them the chance to feedback on the quality of the care provided by the home. Staff members said that some quality assurance surveys were carried out by the local authority however there was no evidence or feed back information available to support this view. The home had recently carried out their own quality audit by sending out questionnaires to residents and their relatives, which was at the time being looked at by the home’s management team. It is planned that the outcome will be written up and discussed at the resident and staff meetings. Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 Page 20 The staff team is shared between the home’s management team for one to one supervision every two months. The manager was said to be approachable and always willing to help. Staff members said they were able to discuss matters relating to their job and any training they wished to undertake. Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x 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 4 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x x 3 x x Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 Page 22 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 7 Regulation 15 Requirement All residents must have a Care Plan which clearly identifies all their care needs with an action plan detailing how these needs will be met. The Registered Provider must make sure that residents have access to an appropriate number of staff taking into consideration the size and layout of the building. The provider must provide residents and other with feedback for survery carried out. Timescale for action 30th November 2005 20th December 2007 2. 27 18 3. 4. 5. 33 24 5th January 2006 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. 2. Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 Page 23 Refer to Standard 3 Good Practice Recommendations The Registered Provider should make sure that all prospective resident have an up to date assessment of care needs. Commission for Social Care Inspection Aire House Town Street Leeds LS2 1HP 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 Kirkland House J52 S33261 Kirkland House V233676 250805 stage 4.doc Version 1.30 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. 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