Inspection on 28/06/05 for Kirklands

This inspection was carried out on 28th 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 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

Kirklands 04/06/09

Kirklands 25/02/09

Kirklands 04/03/08

Kirklands 07/03/07

Kirklands 23/03/06

Kirklands 14/03/05

Kirklands 09/09/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Clover House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Kirklands Sullart Street Cockermouth Cumbria CA13 0EE Lead Inspector Elaine Brayton Unannounced 28 June 2005 at 9.45am 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. Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kirklands Address Sulart Street Cockermouth Cumbria CA13 0EE 01900 822364 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) Anchor Trust Maureen MacColl Care Home 40 Category(ies) of MD(E) - Mental Disorder, over 65 registration, with number OP - Old Age of places DE(E) - Dementia, over 65 LD(E) - Learning Disability, over 65 Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 2. The home is registered for a maximum of 40 service users to include: - up to 30 service users in the category of DE(E) (Dementia over 65 years of age) - up to 7 service users in the category of OP (Older people not falling within any other category 3. One named service user in the category of MD(E) (Mental disorder, excluding learning disability or dementia over 65 years of age) may be accommodated within the overall number of registered places 4. Two service users in the category of LD(E) (Learning disability over 65 years of age) may be accommodatd within the overall number of registered places. Date of last inspection 14 March 2005 Brief Description of the Service: Kirklands is a modern, purpose built home situated in a residential area of Cockermouth. It is within walking distance of all the local amenities in the town centre. The home is operated by the Anchor Trust, who own other care homes across the country, and managed by Mrs. Maureen MacColl. The home provides accommodation and care for up to forty older people, thirty of whom may have dementia. The accommodation is on two floors, and is divided into four living units. Each unit has a lounge/dining room, with bedrooms, toilets and bathrooms close by. The home has a passenger lift and a range of other equipment to assist people in their day to day lives. There are pleasant gardens, with seating areas, which were safe and secure. There is a car park to the front of the home. Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home, and the Pharmacy Inspector was also present throughout the day. During the inspection time was spent in the communal areas of the home talking with residents individually and in small groups, some relatives were also spoken to. Records were looked at relating to the care of service users and day to day running of the home. Time was spent talking to the Manager and staff on duty. All communal areas and some private rooms were looked at during the day. What the service does well: 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. Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 6 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 Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 7 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 The statement of purpose and service users guide provided service users and prospective service users with enough information to enable them to make a decision about moving into the home. The assessment procedure is thorough, and ensures the home is able to meet people’s needs before they move into the home. EVIDENCE: The statement of purpose and service users guide is available in the home and provides people with important information about the accommodation and services provided by the home. A selection of assessments was looked at, and these were very comprehensive and included information about all of the person’s health and social care needs. Information was also taken from health care professionals and social workers when appropriate. This information assisted the senior staff in making a decision about if and how the persons needs could be met in the home. Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 8 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) 7,8,9,10 The care planning systems in the home was good, and ensure service users health and social care needs are met in a way that respects and promotes peoples privacy and dignity. Medicines handling and outcomes were generally good but improvements are needed in some areas in line with good practice guidelines. EVIDENCE: The care plans contained a good amount of detail about residents care needs and how those needs are to be met. They contained information about special care needs with clear guidance and instructions for staff, which have been agreed with the resident and/or their relative. The plans are reviewed and updated on a regular basis to reflect the changing needs of people. Records are kept of all healthcare issues and appointments to ensure residents maintain optimum health. Residents said that the staff were kind and caring, and people were observed being treated in a manner that respected their privacy and dignity. The pharmacist inspector examined medicines handling. Medicines storage was clean, neat and organised. The home had excellent communication with Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 9 their supplying pharmacist who was present at the time of the inspection. The pharmacist provided much support regarding medicines handling and always informed the home staff of issues including changes of medication or appearance. The manager and pharmacist were to meet to further discuss the handling of prescriptions. Primary Care trust pharmacists undertook regular medication review and referred this information back to both the home staff and the pharmacist and this excellent three-way communication ensured smooth and timely implementation of changes. There were a number of issues raised regarding medicines handling including appropriate recording. A number of requirements and recommendations are made to improve practice and staff should adhere to Royal Pharmaceutical Society of Great Britain guidance on safe medicines handling in care homes. An additional visit letter is available with a detailed report of the findings. Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 10 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) 12,13,15 Social Activities and meals were varied, and provided residents with a range of opportunities and choices on a daily basis. EVIDENCE: During the inspection residents were taking part in various activities, such as having a manicure or going for a walk. There were also displays of art and craft based work that had been completed by people in the home. Activities were based on the preferences of the residents, and care was taken to ensure everyone was given an opportunity to take part in something that they enjoyed or interested them, and this could be individually or in a small group. Visitors were welcomed into the home at any time, and were offered refreshments. Residents could spend time with their visitor in one of the lounges or in their own room as they wished. Residents enjoyed a varied and nutritious diet, with a choice of menu at each mealtime. Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 11 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 The home has a satisfactory complaints procedure, which is accessible to all residents and their families. Staff had a good knowledge and understanding of adult protection issues, which protected residents from abuse. EVIDENCE: Residents and their family or advocate are provided with a copy of the complaints procedure on admission to the home. This procedure is also displayed in the home. This provides people with the information they need to make a complaint. Staff spoken to were able to demonstrate their awareness of their role and responsibilities in relation to the protection of vulnerable adults in order to protect people from abuse. Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 12 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) 19,20,21,22,23,24,25,26 The standard of environment in the home is good, and provides service users with comfortable and homely accommodation. Equipment is provided to maximise the health, welfare and independence of service users. EVIDENCE: The home is well maintained, with communal areas, which are pleasant and spacious. Private bedrooms had mostly been personalised with the person’s own furniture, photos, ornaments and soft furnishings, and provided familiar, comfortable accommodation for residents. Each bedroom has an en-suite toilet facility, and in addition to this there are toilets close to communal areas, and bathrooms equipped with assisted baths and showers. Residents are assisted in moving around the home through the use of hand and grab rails, a passenger lift and hoists. The home is clean and hygienic, and the gardens are attractive and well kept. Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 13 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) 27,29 The home has a robust and thorough recruitment procedure, and through this sufficient staff are recruited with the required skills to meet the needs of residents. EVIDENCE: There were eight members of care staff on duty during the inspection. As well as care staff there is always a senior member of staff on duty, an activities person, housekeepers, kitchen staff, a laundry person, a maintenance man and gardener. These staff ensured that the care needs of the residents were met in a relaxed and calm manner, that nutritious meals and snacks are provided throughout the day and the environment is kept clean, tidy and comfortable. Personnel files for new members of staff contained information about the checks carried out to ensure staff are suitable for their role. New members of staff complete a thorough induction programme, and complete training in key areas to equip people with the skills they need to carry out their work. Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 14 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) 31,32,34,35,36,37,38 There is clear leadership, guidance and direction to staff to ensure residents receive consistent good quality care. The systems to protect the finances, health, safety and welfare of residents are effective and well managed. EVIDENCE: The Manager of the home is competent, qualified and ensures her knowledge is updated regularly. There Manager promotes an open and inclusive atmosphere in the home, and this was evident throughout the day when residents often spent time in the office sitting chatting with the Manager and visitors to the home. Staff spoken to say they would always be able to approach the Manager of senior staff member with any problems or issues they had, and believed they would be listened to and addressed satisfactorily. All of the tests and checks were being carried out to ensure the home was a safe place to live, work and visit. Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 15 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 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x 3 3 3 3 3 Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 16 no 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. 2. Standard op9 op9 Regulation 13(2) 13(2) Requirement All medicines entering and leaving the home must be recorded. To ensure safe systems for medicines administration including implementation of a resident identification system. Medicines must be administered as prescribed. MARs must indicate the dates of medicines administration. Reasons for non-administration must be documented. All administrations must be signed for. MARs must not be signed for administration if this has not been undertaken. MARs must specify the dose administered where this is variable. Residents’ records must indicate where medicines are administered by District Nurses. The medicines fridge must be locked at all times. Out-of-date medicines require replacing if they are still needed. Medicines must be disposed of appropriately. Medicines prescribed for one Timescale for action 01.08.05. 01.09.05. 3. op9 13(2) 01.08.05. 4. 5. 6. 7. Kirklands op9 op9 op9 op9 13(2) 13(2) 13(2) 13(2) 01.08.05. 01.08.05. 01.08.05. 01.08.05. Page 17 F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 resident must never be administered to other residents. 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 op9 Good Practice Recommendations It is recommended that the practice of secondary dispensing be reviewed and either discontinued or undertaken to the same standard as would be expected from a pharmacist including the implementation of checking and cross-referencing systems and appropriate labelling Medicines fridge temperatures must be monitored and recorded daily All medicines should be retained in their original packaging. 2. 3. op9 op9 Kirklands F58 F10 s22641 kirklands v220772 280605 ui stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith, Cumbria CA11 9BP 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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