CARE HOMES FOR OLDER PEOPLE
Kirkley Lodge Dalby Way Coulby Newham Middlesbrough TS8 0TW Lead Inspector
Jackie Herring Announced Inspection 10th January 2006 09:30 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 Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 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. Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Kirkley Lodge Address Dalby Way Coulby Newham Middlesbrough TS8 0TW 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) 01642 599080 01642 575182 Anchor Trust Joanne Innocent Care Home 47 Category(ies) of Dementia (12), Old age, not falling within any registration, with number other category (24), Physical disability (11) of places Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st September 2005 Brief Description of the Service: Kirkley Lodge is a two storied purpose built care home for up to forty-seven people in three units. The home has been operating since 1993 and is registered under the Care Standards Act 2000 to provide care for up to twentyfour elderly frail people, twelve elderly mentally infirm people and eleven elderly people with high physical dependency needs. All bedrooms have en-suite toilets and washbasins and have letterboxes in their doors. All rooms are fitted with call alarms. Each downstairs unit has its own lounge/diner with a small kitchenette to allow staff and residents to make drinks though main meals are provided from the home’s kitchen. The upstairs unit has two lounge/diners. Each unit also has a quiet lounge and provides residents with a choice of assisted baths or showers. The home has a main kitchen and well-equipped laundry to meet resident’s needs. A hairdressing room is also available. The home has attractive large garden areas ample car parking facilities. It is located in a convenient position with local shops, services and recreational facilities being in easy walking distance and is close to bus routes. Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was an announced inspection and took place over one inspection day, six and a half inspection hours in total. A pre inspection document was completed along with a large number of resident and relative questionnaires. Discussion took place with residents, one relative, staff, the manager and deputy manager. A number of records were examined, including staff files, personal allowance records and a small number of policies and procedures. The inspection was a very positive experience, the home was warm and friendly and there was a very open culture in which vision and drive for continuous improvement was very evident. What the service does well:
Kirkley Lodge is an extremely well managed care home offering a high standard of care to the residents and is a very supportive and enabling environment for the staff to work, which ultimately impacts upon the quality of care and quality of life for the residents. The staff are well trained, very knowledgeable and can competently meet the needs of the residents. Residents described being very happy at Kirkley Lodge and the interactions observed between staff and residents were very warm and caring and it was obvious that very good relationships had been developed. Residents said, “the home was alright before, now it’s the best it has been, I can now make many more decisions and be more independent”, “ The managers are fully aware of what goes on in the home, they will always come and help me with my care”, Relatives said, “Mum had been at Kirkley Lodge for 6 years and the improvement in her has been remarkable. The staff are so kind and caring towards mum, and myself and my family cannot begin to thank them enough. It is a pleasure to see her so obviously well looked after and content, all down to the dedication of the staff!” “I have a lot of admiration for the staff. They work very hard and do a very difficult job as well as anyone could. Mother is as happy as possible under her circumstances”. Kirkley Lodge provides a pleasing, comfortable and inviting environment for the residents to live, in which there is a good sense of space and warmth. Staff said of what Kirkley Lodge did well, “residents needs are well met, there it a good, vigilant and well trained team of staff and it is wonderful to see people develop and achieve things”.
Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 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 Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were examined on this occasion. EVIDENCE: Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were examined on this occasion. EVIDENCE: Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 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 the following standard(s): 12 Activities are now being well managed and residents recreational and social needs are being provided for. EVIDENCE: Since the last inspection, the activities within the home have been reviewed as has staffing for this. It has been confirmed by the Area Manager that it was highly likely that following budget agreement, funding would be available for this and that a member of staff would be appointed specifically to coordinate and deliver activities. The manager confirmed that in the meantime, a key member of staff had been developing activities within the home. On the day of the inspection, a bingo session was being held and everyone was very enthusiastic about it and it was confirmed through the pre inspection document that a range of activities had been developed and introduced. Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 11 Although meals were not looked at in detail, the inspector joined the residents within the dementia care unit for lunch. This experience was positive, the environment was relaxing and calm and it was very evident that residents were offered choices. Staff were very excited about a recent course they had completed, Dining with Dignity. They said it really made them much more aware of the needs of people with dementia and they had changed their practise as a result. Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Robust systems are in place for concerns and complaints and to ensure protection of residents. EVIDENCE: Complaint records were examined during the inspection. There had been two complaints since the last inspection of a minor nature, however these were well recorded and demonstrated a thorough compliant and investigation system. Residents were very confident in the staff and manager that if they had any concerns they would be handled appropriately. The complaints procedure was well written and detailed and was very clear in regard to the types of complains and the various stages. The appropriate policies and procedures were also in place for the protection of vulnerable adults and staff confirmed through interviews that they had received training on the topic of abuse and the procedures to follow in the event there was a need. Evidence of abuse and no secrets training was contained within the individual staff members training files. Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25, 26 Residents continue to benefit from a very attractive, homely and wellmaintained environment offering spacious bedrooms and comfortable and welldecorated communal areas. The home continues to be commendably clean but more regular checks of the temperature of the hot water supply continue to be necessary to improve the safety of residents. EVIDENCE: A requirement from the last inspection was in relation to the hot water, which is regulated to baths, showers and washbasins to ensure that hot water is delivered at close to 43oC. It had been identified that records were available to show that the temperature of hot water delivered is tested periodically and that the temperature of bath water is taken and recorded prior to bathing residents. Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 14 It was noted, however, that the temperature of hot water delivered from each bath and shower was being taken once in four months. This is not frequent enough to offer sufficient monitoring of the need for adjustment of these devices or protection from the risk of failure. The home must ensure that the outlet temperature of water to all baths and showers is monitored and recorded weekly as advised by Health and Safety Executive guidance. It is of concern that despite discussion with Anchor Homes Health and Safety Department, that no action has taken place and this remains an outstanding requirement from the last inspection. Kirkley Lodge continues to be a homely, comfortable and clean environment for the residents to live and there is a clear sense of space and warmth within the home. Within the relative’s surveys, there were some minor comments about the laundry, the cleaning of resident’s bedrooms and the possible replacement of the corridor carpet on the Roseberry unit. These comments were raised with the manager who confirmed that she was aware of them and was taking the appropriate steps to attend to. Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Very good procedures are in place for the recruitment and selection of staff and care is provided to the residents by a very well trained, competent and dedicated team of staff. EVIDENCE: The duty rota was examined during the inspection and demonstrated a very good staffing level and skill mix of staff, which exceeded the minimum requirements, however was necessary to meet the different needs of residents within the home. Despite there being a good level of staff on duty, a number of relatives surveys stated, “I do think the staff are overworked and feel that more staff are needed on each unit”, “There should be more staff on duty, particularly at mealtimes”, “There sometimes seems to be a lack of carers”. Four staff files were examined and contained all of the information needed, which demonstrated very good recruitment practises. Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 16 A number of relative surveys were received and contained a number of comments, “Mum had been at Kirkley Lodge for 6 years and the improvement in her has been remarkable. The staff are so kind and caring towards mum, and myself and my family cannot begin to thank them enough. It is a pleasure to see her so obviously well looked after and content, all down to the dedication of the staff!” “I have a lot of admiration for the staff. They work very hard and do a very difficult job as well as anyone could. Mother is as happy as possible under her circumstances”. Training records were also examined and there were personal training profiles and personal development plans for all of the staff. Staff were very enthusiastic about some recent training, which related primarily to the residents within the dementia care unit, staff said, “Dining with dignity is the best course I have attended”. Currently, 71 of staff are trained to NVQ Level 2 with other staff trained to level 3 and 4. It was also evident that developing the staff team was very important and staff undertakes specific roles within the home such as health and safety and back care. During discussion with staff they spoke very highly of the training opportunities made available to them, one staff said, “there is a real commitment to training and development and I have seen myself become more confident and the team generally have become much more aware of their responsibilities”. During interviews with staff and informal discussions, very strong values were expressed in regard to residents rights and independence. One relative survey stated, “I think that Kirkley Lodge is a wonderful care home. The staff are not only always pleasant and friendly but are extremely professional and always offer a very high standard of care. I am very impressed”. Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The manager provides very good leadership to the staff team and continuously strives to improve standards within the home ensuring that resident’s needs are well met. Good systems are in place for the handling of resident’s personal allowances and there is also a good range of quality assurance systems. Service and maintenance arrangements are in place and in the main in order, however the fire evacuation procedures is in need of review and the recommendations made by Cleveland Fire Brigade need to be fully actioned to their satisfaction ensuring that the health and safety needs of residents are met. Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 18 EVIDENCE: The manager has the skill and experience necessary for Kirkley Lodge and has the required qualifications. She is extremely enthusiastic about her role and her commitment to Kirkley Lodge was very obvious on the day of the inspection. This commitment and enthusiasm was evident throughout the staff team who were very positive about the work they did. Staff said, “the current manager has made a difference to the home, we are much more geared up to the clients and the clients needs”, “the management team are very fair and supportive and very enabling”, “Kirkley Lodge is without a doubt well run and well managed”. One resident said, “the home was alright before, now it’s the best it has been, I can now make many more decisions and be more independent”, “ The managers are fully aware of what goes on in the home, they will always come and help me with my care”, “the managers are marvellous, they shouldn’t have to do the care work”. Relatives surveys stated, “This is an excellent home it provides very good care and achieves excellent well being of it residents”. The management of resident’s personal allowances was discussed with the manager and financial administrator. The system has recently changed and is much more of a computer base system, which was observed to contain a good level of detail and information. Quality Assurance was discussed with the manager who said that there was a self-assessment tool, which was in the process of being relaunched. She also confirmed that there were regular residents meetings, which are minuted; staff meeting and unit meetings, in which there is a focus on assessing and improving the service to residents. The manager also said that over the last year there had been quite a number of questionnaires completed and Lang and Bussan had undertaken a survey. The manager also described other forms of internal audit, such as care plans, supervision records, medication and the environment. A random sample of maintenance records were examined during the inspection such as fire alarm system, passenger lift and gas landlord certificate and all found to be in order. They were also detailed within the pre inspection documents. Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 19 Following a previous inspection from Cleveland Fire Brigade, there remained some recommendations that were yet to be actioned. The manager has taken immediate interim action in terms of minimising risk and increasing protection, however the matter is currently being dealt with by Anchor Homes Health and Safety Department. The issues primarily relate to the vertical evacuation at night of all residents from the home should there be a need and also additional protection of fire doors, which currently have letter boxes fitted which do not meet the required fire legislation. Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X 2 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 4 X 3 X 3 X X 2 Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP25 Regulation 13 Requirement The organisation must ensure that the outlet temperature of water to all baths and showers is monitored and recorded weekly as advised by Health and Safety Executive guidance. (This is outstanding from 7/10/05) The recommendations made from Cleveland Fire Brigade regarding bedroom doors, letterboxes and a review of the evacuation procedure must be addressed to the satisfaction of the fire service. Timescale for action 28/02/06 2. OP38 23 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kirkley Lodge DS0000000090.V266308.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Tees Valley Area Office 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
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