Inspection on 21/09/05 for Kirkley Lodge

This inspection was carried out on 21st 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

Kirkley Lodge 04/05/07

Kirkley Lodge 10/01/06

Kirkley Lodge 08/12/04

Kirkley Lodge 15/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Kirkley Lodge Dalby Way Coulby Newham Middlesbrough TS8 0TW Lead Inspector Stephen Smith Unannounced Inspection 21st September 2005 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.V250416.R01.S.doc Version 5.0 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.V250416.R01.S.doc Version 5.0 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.V250416.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Manager (Mrs Joanne Innocent) should undertake an appropriate course of training in relation to people with a dementia (of not less than three weeks duration). The training must be arranged with a recognized organization with expertise in the provision of Dementia Training. This training should be completed by April 2004. 8th December 2004 Date of last inspection 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.V250416.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and inspection commenced as 9:30 am and inspection concentrated on the National for Older People relating to Health and Activities and the Environment. carried out by one inspector. The lasted for six and a half hours. The Minimum Standards for Care Homes Personal Care, Daily Life and Social During the inspection a selection of care plans were examined as were various other records maintained by the home. A tour of the premises was undertaken, the home’s medication procedure and practice was inspected and the inspector spent time talking to staff members and residents and seeking their views. The inspector enjoyed a pleasant lunchtime talking to a group of residents round the table. What the service does well: Kirkley Lodge offers a very homely, comfortable and well decorated environment. It has large pleasant bedrooms and spacious well decorated lounges and dining rooms. Bathrooms have all the necessary aids to allow people to bathe comfortably and safely. The gardens are very pleasant areas that the manager intends to improve further. The home is good at working with residents and their families, before they come to live at the home and after they move in, to find out the sort of care that people need and want. It is very good at making plans to meet people’s needs and providing good quality care. A lot of work is done with other professionals to support residents and the home works hard to make sure that residents changing needs are met. Residents’ health needs are well met and a lot of effort is made to protect residents from falls. The home provides a good choice of meals and the food is of good quality. Residents are able to choose from a wide range of options and the home is very flexible in meeting individual preferences and dietary needs. The home provides and supports residents to take part in a range of social and leisure activities. Planned activities are available but residents can also be accompanied by staff on outings to the local town. It is particularly good that the home has such good relationships with residents’ families and involves them frequently in the home’s activities. Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 Page 6 It was evident from the inspection that the home’s manager and deputy are very experienced and work hard to continue to improve the service provided by the home. It was also evident that very good relationships exist between staff and residents, a large number of the people spoken to said that the home has a very good atmosphere. 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.V250416.R01.S.doc Version 5.0 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.V250416.R01.S.doc Version 5.0 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): 3, 5 and 6 Kirkley Lodge does a very good job of finding out the needs of new residents and planning how these needs will be met. EVIDENCE: The care plans of three residents were examined during the inspection. All contained evidence of a detailed assessment of the person’s needs being carried out by the home regardless of whether a care management assessment had taken place. These assessments covered the all the areas set out in the Care Homes for Older People National Minimum Standards including health and personal care needs, dietary and medication needs, cognitive needs and social, religious and cultural needs. Clear evidence was in place in these assessments being reviewed and updated on a regular basis. It was positive to note that assessments contained comprehensive information about the resident’s background and past including information about their jobs, families and friends and events that happened to them. One file contained a newspaper cutting about the work achievements of the resident. Detailed plans of care were in place for the residents whose files were examined. Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 Page 9 Fracture and Falls Risk Assessments have been completed, in conjunction with the National Osteoporosis Society, for the residents whose files were examined in an initiative to reduce injuries from falls. Staff members spoken to were aware of the contents of residents’ assessments and were clearly aware of how these documents are updated to reflect changing needs. Residents spoken to said that staff members talk to them about their needs and were aware of their care plans and records kept about them. Evidence from discussion with residents and from information within care plans examined showed that residents are able to visit prior to moving in. One resident said, “My family looked at a few homes and brought me to see this as they thought it was the best. I think it is really lovely and I’m settling in.” The resident also said, “There is a trial period but I’ve decided I’m staying anyway, I think that I’ve made a good decision.” Kirkley Lodge does not provide intermediate care so Standard 6 above is not applicable to this home. Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 10 The home plans well for and is good at meeting the health, personal and social care needs of the people who live there. EVIDENCE: The home’s care planning system is well structured and contained specific, detailed guidance for staff about how to meet the needs of individual residents. During the visit the inspector spoke to five residents who said that they are well cared for, comments included, “The staff are very good.”, “We have god relationships with the staff.” and “We can have a bit of fun with them.” Residents’ views and preferences are recorded in their plans of care and it was good to note that plans contained information about the whole person not just their needs. Residents spoken to said that they are treated with respect and provided with dignity, they said that a lot staff have worked at the home for a long time and that relationships between staff and residents are very good. Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 Page 11 The staff members spoken to know the people who use the service well and are experienced in working with older people and all residents spoken to spoke highly of the care provided by the home. One said, “I have district nurses who come in to (treat me) and they say that they go into a lot of homes an d that this is the best. I agree with them, it couldn’t be bettered.” Care plans inspected contained agreements about who information could be shared with and contained a lot of information about families, friends and other people involved. It was also apparent from records that the manager and assistant manager have good oversight of the care plans and make sure that they are up-to-date, appropriate and that information is correctly recorded. Care plans examined contained records of all health treatments sought for residents and showed that the home works closely with health services to ensure that residents get the treatment they need. Good records of medical appointments were in place including dental, audiology and dietician appointments. All files examined contained a fracture and Falls Risk Assessment carries out with the National Osteoporosis Society as well nutritional, bathing and pressure sore assessments. Residents said that their health needs are looked after. Records of accidents and incidents are well maintained with clear records being retained centrally and in the file of the person concerned. An effective system of analysing accident and incident records is employed to identify any patterns or trends. The home’s system for storing, administering and recording medication was seen to be well structured, effective and well controlled and managed. Storage is safe and complies with the relevant regulations and records of medication received at the home, given to residents and returned to the pharmacy were seen to be accurate and allowed accurate audits of medication stocks to take place. Records controlled drugs were well maintained. Agreements were in place in the care plans examined about who information about the person could be shared with; these had been agreed by the person concerned. Residents are able to have their own telephones in their rooms but the home also provides a public telephone that offers privacy for any resident using is. Information about privacy and dignity is available for staff in the home and staff members spoken to were very aware of the need to afford residents privacy and dignity in all interactions with them. Residents spoken said that staff look after them well and are sensitive to their needs. Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14 and 15 Residents’ daily lives are generally enhanced by the social activities provided by the home and by the welcome it extends to residents’ visitors. Dietary needs of residents are well catered for. EVIDENCE: The residents’ care plans examined contained information about residents’ interests, hobbies and preferences and risk assessments were in place as appropriate regarding activities or access into the community. Evidence was available from discussion with the manager, deputy and two staff members as well as from residents and recording in their files, that staff accompany residents on outings to the local shops. During the inspection a resident was watering plants in part of the garden and it was apparent that work is being undertaken to encourage the involvement of residents and their families in the design and upkeep of the garden areas. Photographs of activities, events and functions are displayed throughout the home and these showed that a variety of events take place. Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 Page 13 The manager and a staff member told the inspector how the adjoining day centre is used for birthday celebrations and other functions and photographs confirmed this. On the day of the inspection activities were taking place in the home supported by staff and paintings were displayed on the wall that had been done by residents the night before. A hairdresser was present in the home during the inspection as well. During the inspection it was apparent that visitors are welcome; a number of residents were seen to be arranging with staff regarding meals as they were going to be out of the home for tea or the next day’s lunch. Observation during the inspection suggested that the home provides a sufficient level of staffing to meet residents’ needs. Two residents who had lived at the home for a number of years, however, said that staff members have less time to support their social activities than they did in the past as the needs of new people being admitted to the home are such that they need a higher level of support than previously. One said, “We see less of the staff now as they are busier with new people who need more help.” The registered provider should keep staffing levels review to ensure that the home continues to be able to meet residents’ social and activity needs. Agreements are in place in the residents’ files examined regarding the level of information to be shared and clear consultation with families had taken place when assessing residents on their admission to the home. During the visit the inspector enjoyed a very pleasant lunch with a number of residents. During this meal the residents shared openly with the inspector their experiences of the home and their views are reflected in this report. The inspector would like to express his gratitude for their welcome and conversation. Lunch was of very good quality and attractively presented and served. Observation showed that are offered choices at every meal and that other alternatives are available to residents if they do not want the main choices. Residents’ care plans contained detailed nutritional assessments and information as well as records of food and dietary preferences. Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 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 the following standard(s): The standards relating to Complaints and Protection were not assessed at this inspection. EVIDENCE: Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Residents benefit from a very attractive, homely and well maintained environment offering spacious bedrooms and comfortable and well decorated communal areas. The home is commendably clean but more regular checks of the temperature of the hot water supply are necessary to improve the safety of residents. EVIDENCE: The home is spacious and accessible and a great deal of work has taken place to make sure that it offers a homely environment despite its size. Garden areas are also accessible to residents and work has been done to make sure that these are very pleasant, well maintained areas with further work planned. The manager informed the inspector and provided evidence to confirm that a large amount of work is planned to the home’s fire alarm system and suspended ceilings as well as work to fit door closing mechanisms linked to the fire alarm system to all bedroom doors. Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 Page 16 The manager said that this work is planned following a visit from the fire officer and that the home is to be fully redecorated after this work has taken place. Communal areas are roomy, accessible and pleasantly decorated. The lounge diners are pleasantly furnished and the small kitchenettes in these areas are a positive and well-used feature. The home offers residents a choice of taking a bath or shower and provides enough assisted bathing facilities to meet residents’ needs. The home has recently installed a range of new assisted baths to meet the needs and preferences of residents. Bedrooms all contain an en-suite room of generous size that contain a toilet and washbasin. Hoists and lifts are provided by the home for the assistance of residents and evidence was available in the maintenance file to show that these are services appropriately. All bedrooms have call alarms and comfortably exceed the minimum required size. Bedrooms seen during the inspection contained all the furnishings set out in the Care Homes for Older People National Minimum Standards and were well decorated. It was noted during the visit that residents are able to bring their own furniture and belongings into the home and this was commented on very positively by a resident who had just moved into the home who said, “It helped me feel very much at home, I would have hated having to leave everything behind.” The home provides a comfortable environment for the residents; on the day of the inspection the home was appropriately heated, ventilated and lit. Emergency lighting is in place and radiators and pipework are guarded to protect residents from hot surfaces. The home’s hot water supply is managed appropriately with water being stored at high enough temperatures to prevent legionella and a detailed risk assessment and strategy is in place. Hot water is regulated to baths, showers and washbasins to ensure that hot water is Records were available to show that the delivered at close to 43oC. temperature of hot water delivered is tested periodically and that the temperature of bath water is taken and recorded prior to bathing residents. 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. Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 Page 17 The home has a commercial laundry facility that enables it to make sure that laundry undertaken provides suitable disinfection of any items. The laundry is sited away from the kitchen and is well laid out with easily cleanable floor and wall surfaces. The home was noted to be commendable clean and free form odours at the time of the inspection and it is evident that the home makes effort to provide a clean pleasant environment for the residents. Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 Page 18 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): The standards relating to Staffing were not assessed at this inspection. EVIDENCE: Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards relating to Management were not assessed at this inspection. EVIDENCE: Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 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 3 X 3 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 Page 21 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. 1 Standard OP25 Regulation 13 Requirement 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. Timescale for action 07/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations The registered provider should keep staffing levels under review to ensure that the home continues to be able to meet residents’ social and activity needs. Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 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 © 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 Kirkley Lodge DS0000000090.V250416.R01.S.doc Version 5.0 Page 23 - 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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