Inspection on 01/12/09 for Kirksanton Care Centre

This inspection was carried out on 1st December 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kirksanton Care Centre 01/12/08

Kirksanton Care Centre 10/06/08

Kirksanton Care Centre 30/05/07

Kirksanton Care Centre 16/10/06

Kirksanton Care Centre 08/05/06

Kirksanton Care Centre 19/10/05

Kirksanton Care Centre 23/06/05

Kirksanton Care Centre 04/03/05

Kirksanton Care Centre 23/08/04

Kirksanton Care Centre 30/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report Care homes for older people Name: Address: Kirksanton Care Centre Kirksanton Care Centre Kirksanton Millom Cumbria LA18 4NN     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Marian Whittam     Date: 0 1 1 2 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 39 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 39 Information about the care home Name of care home: Address: Kirksanton Care Centre Kirksanton Care Centre Kirksanton Millom Cumbria LA18 4NN 01229772868 01229774015 enquiries@guardian-care.com www.guardiancarehomes.co.uk Guardian Care Homes (UK) Limited Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Christine Munroe Type of registration: Number of places registered: care home 45 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The registered person may provide the following categories of service only. Care home only - code PC, to people of the following gender:- Either. Whose primary care needs on admission to the home are within the following categories: - Old age not falling within any other category - Code OP, (maximum number of places: 25) Dementia Code DE The maximum number of people who can be accommodated is: 45 Date of last inspection Brief description of the care home Kirksanton Care Centre is owned by Guardian Care Homes. This company own other residential and nursing homes in England. The home has three distinct areas. The original house has been renovated to accommodate up to 10 people who have dementia. This part of the building is known as The Croft. Not all of these bedrooms Care Homes for Older People Page 4 of 39 0 1 1 2 2 0 0 8 45 0 Over 65 0 25 Brief description of the care home have ensuite facilities but all have bathrooms near to the bedrooms. This area has two lounges for shared use. The home also has a more modern annex built on to the original building where up to 25 older people -- who may or may not have dementia -are accommodated. This area has a large lounge and a dining room. Some rooms in this part of the building have ensuite bathrooms, others have washbasins only. The Mews building is connected to this central part of the home. Younger people with a diagnosis of alcohol related dementia (Korsakoffs syndrome) live in this Mews building. The Mews is set out as self-contained apartments with their own lounge/kitchen, bedroom and bathroom. There is a lounge where people may smoke and a small kitchen and dining area. Information about the service can be obtained from the home, its Statement of Purpose and service guide or from the providers website. Charges for care range from 384 pounds per week to 577 pounds per week but this home has a very individualised charging system that depends on the level of dependency of each person. Care Homes for Older People Page 5 of 39 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for Kirksanton Care Centre is 1 Star. This means that the people who live there and use this service experience Adequate quality outcomes. This site visit to Kirksanton Care Centre forms part of a key inspection. It took place on 1.12.2009. We gathered information about the service in different ways in order to help us make a judgement: We sent an Annual Quality Assurance Assessment (AQAA) form to the home and this was completed by the registered manager, Christine Munroe, and returned by the date requested. The AQAA is a self assessment and a dataset that is completed annually by all providers of registered services. It is one of the ways we gather information from the providers of services about their service and how they believe they are meeting outcomes for the people living there and using their service. The AQAA also gives us statistical information about the individual service and trends and patterns in social Care Homes for Older People Page 6 of 39 care. We sent out surveys to people living at Kirksanton and to the staff who work there to get their views and experiences of the service. We also sent out surveys for people living there to give to, if they wished, their relatives, friends and advocates who come into contact with the service. We looked at all the information we have about the service, any changes they have made and how the manager has dealt with any complaints or safeguarding vulnerable adults. We looked at what the manager has told us about things that happened in the service, these are called notifications and are a legal requirement. We looked at the previous key inspection and action plans and any calls or visits we have made to the home since their last inspection. We spent time talking to people who live there, and spent time with them during the day to see what happens during their day and see what they think about the way the home is run for them. We also spent time talking with staff to get their experiences of working there. We looked at any relevant information we had received from other agencies and organisations and any written comments people have made to us. During the day we spent time talking with people living at Kirksanton in the communal areas and also in private in their rooms. We looked at care planning documents and assessments to make sure that people received the level of care they needed and expected. We made a tour of the premises to look at the environment people live in and what facilities are available to them. We also looked at staff training and recruitment files and a sample of records and safety assessments required by regulation. The pharmacist inspector examined the handling of medication during the visit by looking at relevant documents, storage and meeting with the manager, Christine Munroe, and other staff. The pharmacy inspection took five hours. Care Homes for Older People Page 7 of 39 What the care home does well: What has improved since the last inspection? Since the last inspection the service has reviewed and updated its Statement of Purpose and service user guide to help make sure they give up to date information for people thinking of using the service. We looked at these new updated documents and they contained the relevant general information about the services offered for older people and a better indication of the intended aims of the service. Work has been done, since the last inspection to improve the care plans being kept up to date and evaluated with monthly reviews. It was evident that the manager had been trying to improve the use of the care plans to be more focused on individuals and we were shown new documentation developed to reflect care more focused upon them as individuals. These had not been implemented yet and so we could not assess their practical value but would hope to see them being effectively used at our next visit. There was a programme of activities for people living there and we could see staff spending time with the older people and supporting older adults to participate. We could see from the records held and our observations that training was being given greater importance and more training provided to improve staff knowledge and skills. The manager has made improvements in training provision as recommended at the last inspection mainly including safeguarding, managing challenging behaviour and dementia care training. The training records indicated that staff had been given the mandatory training required and they had completed mandatory training on manual handling training, fire training at appropriate intervals, food hygiene training and a Care Homes for Older People Page 8 of 39 number of staff with First aid training. The manager showed us the services Business plan commenced October 2009 and this had plans to address organisational issues . Areas such as capital expenditure, occupancy levels, the current market and the services perceived strengths and weaknesses were looked at. The manager now does some monthly checks on medication, care plans and the premises and provides a monitoring report for head office. This helps monitor quality in these areas. Quality assurance systems continue to be improved with more residents meetings and the use of surveys. Since the last inspection the organisation has reviewed its complaints policies and procedures to try to develop robust reporting processes to help make sure people feel that they can make complaints or suggestions and that any issues will be acted upon. The management has also taken action to improve the training provided to staff on safe guarding people from abuse and recognising what forms abuse may take and on promoting individual rights. Training records also indicated that training had been provided to staff this year on understanding Deprivation of Liberty legislation and upon the Mental capacity Act that may affect the rights of people living in residential homes. Improvements have been made to the heating systems in the home to make sure the home is appropriately heated. Areas for improvement highlighted in the homes improvement plan have received attention and several areas are still ongoing or not fully implemented. The management needs to continue the work and show a consistent improvement in the areas of weakness and in recognising and managing them. What they could do better: The service users information says the service provides for the needs of younger adults but the information provided for people does not make clear how this is done and people may be enabled to take part in age, peer and culturally appropriate activities to promote their independence and personal development. The manager needs do this this to make sure they give both younger and older people considering, and presently using the service, the most comprehensive information to help them know the home will support and assist them to live the life they chose. There was little indication of peoples involvement in developing their own plans or that they had led their admission process. The manager should look at providing ways to make the admission process more personalised and focused upon achieving the outcomes people wanted when they got there. For some younger adults living there, their individual care plans lacked sufficient detail and information on how to manage some behaviours and their plans did not explore strategies to help and support them manage their conditions or behaviours and enable their independence and personal development. The manager also needs to consider the different lifestyle aspirations of the younger adults living in the home and put in place systems to consult with them and to provide and support them with opportunities for personal development, independence and to enable integration into wider community life. This is to help ensure that people will be enabled to take part in a variety of social activities, educational and work opportunities and have lifestyles where they can be independent Care Homes for Older People Page 9 of 39 and achieve their personal potential. Given the complex needs of people especially the chronic conditions and cognitive impairments experienced by some of the younger people living there the manager should consider obtaining more specialist training and practical skills in this practice area. The manager should also make sure that assessed nutritional needs and plans give clear instructions and these are followed by all staff to make sure people receive the nutrition support they need. To improve medicines management care plans need to provide staff with clear guidance on managing people with specific care needs for the administration of complex or when required medication so that they are managed safely and effectively. Where care staff require training in specialist administration of medication the records need to show that the health care professional taking overall responsibility for treatment has delegated the task to staff who they have assessed as competent. The manager needs to ensure that staff who carry out any specialist or invasive techniques in the home have a formal assessment within a clear framework of the competencies needed for the task. It should be made clear that the task has been delegated by the district nurse to specific staff for the individual needing it. The manager also needs to introduce a safe system of handling and recording the disposal of medication that has been refused by residents. Although complaints processes have been improved the manager needs to make sure they always keep complete records of all complaints received so it can clearly be seen that appropriate action has been taken to satisfy all parties involved and protect peoples best interests. The manager should consider the provision of a non smoking lounge in the Mews and make sure the arrangements in use meet the Local Authority guidelines on smoking rooms and bedrooms to ensure best and safe practice in this respect. A cleaning regime was in place to combat smells arising from incontinence problems but this does not appear to be fully effective and the manager needs to seek more expert advice on dealing with this difficult problem. The provision and monitoring of training has overall been improved but the manager should make sure staff have updates on infection control to help make sure staff are up to date with best practice. They should make sure that all staff are given updates on Health and Safety responsibilities and processes, especially where staff have had a change in role affecting those responsibilities. Quality assurance systems continue to be improved but the manager makes sure there is a system in place to make sure all policies and procedures are reviewed on an annual basis at least. This is to make sure they reflect changing legislation and good practice. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. Care Homes for Older People Page 10 of 39 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 11 of 39 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 12 of 39 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Kirksanton Care Centre needs to review the service users information provided to be clearer about how they actually enable younger adults to make decisions about their lives and achieving their goals. Evidence: The service has a Statement of Purpose and service user guide. These are in the final stages of a review to help make sure they give up to date information for people thinking of using the service. We looked at these new updated documents and they contained the relevant general information about the services offered for older people and a better indication of the intended aims of the service. However, given that the service accommodates and supports younger adults, as well as older, the information being made available to people needs to be clear and explicit on what services both, specialist and general, are available to meet the needs and life expectations of younger people thinking of coming to live there. The home information says it provides for the needs of younger adults but the information provided does not make Care Homes for Older People Page 13 of 39 Evidence: clear how this is done. For example how they will enable them to make decisions about their lives, how people will be enabled to take part in age, peer and culturally appropriate activities and recreation including education and learning practical life skills to promote their independence and personal development. We recommended to the manager that they need do this this to make sure they give both younger and older people considering, and presently using the service, the most comprehensive information to help them know the home will support and assist them to live the life they chose and achieve personal goals and potential. This lack of clarity was supported by some survey responses we received from people living in the home that indicated that some people were uncertain about the level of information they had before they came in. Relatives who responded did however feel their relative had been given information to help make a decision and that they were aware of the information. The manager told us that the statement of purpose and service guide and last inspection report are normally displayed in the foyer with the signing in book for visitors. However they were not there on the day of the visit and the manager told us someone must have taken them to read. The manager confirmed they would be replaced. The complaints procedure and general information leaflets on support agencies and fees were displayed in the current entrance area. We looked at the pre admission assessments of five people in detail to see if their individual needs had been assessed before admission to help make sure that the home would be able to meet their needs when they came in. This included a person who had recently come to live there and people who had been living there for varying amounts of time. The pre admission assessments were on file with current care plans and included family information, useful background information on hobbies and interests that could be used to develop individual recreational plans with people. There were also cognitive assessments and any behavioural or mental health issues staff needed to be able to meet. The information covered relevant areas of assessment to begin developing a plan of care with someone. However from speaking to people and looking at the assessments on file there was little indication of peoples involvement in developing their own plans or that they had led their admission process. We recommend that the manager looks at providing ways to make the admission process more personalised and focused upon achieving the outcomes people wanted when they got there. There were also social services care management plans from assessing social workers on file for these people. There was also recorded evidence that people had been involved with reviews of their care annually with social workers, their families and the home manager and key workers. This was to help make sure their needs were still being met and the placement was still appropriate. Care Homes for Older People Page 14 of 39 Evidence: Care Homes for Older People Page 15 of 39 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Kirksanton have their needs assessed but a lack of information and clarity on some aspects of individual and behavioural support and medicine administration can undermine the practical effectiveness of the support being given. Evidence: All people living in the home have a plan of care developed based on initial assessments and risk assessments setting out health, personal and social care needs and these are being regularly reviewed and audited. We looked at five peoples care plans in detail. Three of these were for younger adults living in The Mews and two were older adults living in the main building of the home. Work has been done to improve the care plans being kept up to date and evaluated with monthly reviews. The care plans showed the persons keyworker and some information on what staff needed to do to support people including on a persons mobility, diet, health care needs and their social and religious preferences. Appropriate risk assessments for skin care were in place and appropriate equipment to prevent pressure sores for those at risk were seen in use. Basic nutritional screening is in place and peoples weight is Care Homes for Older People Page 16 of 39 Evidence: monitored and recorded. We could see from records that people had access to health care services, had their own GPs and if they needed were attended by the District nursing service in their own community. We found overall that care plans were being evaluated and that records of personal care being given was recorded. However we found, most evidently with younger adults living there, that in some respects their individual care plans lacked sufficient detail and information on how to manage some behaviour that a person may exhibit. Care plans did not explore strategies to help and support them manage their conditions or behaviour and enable their independence and personal development. Although needs were being assessed there was little practical guidance for staff on recognizing triggers or dealing with any unpredictable behaviour. There was a lack of forward planning with people to make sure their emotional and cognitive needs and well being were being promoted through clear strategies to help them develop life skills for independence and manage their conditions. This lack of depth and planning with people could result in individuals not getting the support they needed to be as independent as they could be or achieve all that they can as individuals and may also place others in danger. For example, despite some people exhibiting prior aggressive, inappropriate and addictive bahaviour there were no plans in place to address or support people through this now. No guidance on what might precede or trigger these hehaviours, or what to look for and monitor or the agreed ways of managing them should they occur. We asked staff about support programmes for dealing with behavioural issues for people living in the Mews. They told us about the work they were doing with one person to support them to be more independent but we could not find any agreed plans to do this or monitor and evaluate the success of any support programme. A younger person had short term memory problems had no aids or support plans in place to help them with remembering. Appropriate aids such as diaries and calendars could help them be more able to handle their condition in daily life and interactions. Staff were not aware of any such strategies for that person. We saw a persons plan where they were assessed nutritionally as at risk of choking and a thickening agent was to be used with meals and drinks to reduce this risk. This person was eating rice crispies with unthickened milk on their food and in their drinks. The care plan advised a semi soft diet but there was no information to define what that should be such as puree or liquid or somewhere in between. The person was coughing as they ate as the cereal had not been soaked to make it soft. The surveys we received from people living at the home and their relatives did not raise any issues regarding care in the home. People living there indicated satisfaction with their personal care and medical access and made some individual comments, including, The staff are always here and are nice and helpful and Good food, the Care Homes for Older People Page 17 of 39 Evidence: staffs alright and Everything is very nice and all the staff are very nice. The approach we observed staff taking with people was calm and staff explained what they were doing. We saw this was the case when staff were helping people using hoists to sit in comfortable chairs. It was evident that the manager had been trying to improve the use of the care plans to be more focused on individuals and we were shown new documentation developed to reflect care more focused upon them as individuals. These had not been implemented yet and so we could not assess their practical value but would hope to see them being effectively used at our next visit. The pharmacist inspector examined the handling of medication by looking at relevant documents, storage and meeting with the manager, Christine Munroe, and other staff. The inspection took five hours. Feedback was given to the manager at the end of the inspection. Overall, we found that records were good but further work is needed to develop effective care plans relating to medication in order to fully protect the health and well-being of residents. We looked at records for receipt, administration and disposal of medication for a period of just over four weeks. These were accurately completed and showed the treatment received by residents and, if medication was not given, the reasons for omission. We saw only one record for a liquid nutritional supplement that was prescribed four times a day that was not fully completed. In this case there was no evidence that the night-time feed had been given on seven occasions in a four week period. This means that over this time the resident missed the equivalent of nearly two days of nutrition. We were also concerned that staff used jam jars in which to place medicines that were refused by one resident. This resulted in jars containing mixtures of medications that could not be positively identified and this is a hazard. We counted a sample of medicines and compared these with records to check if they tallied and to show they were administered in the prescribed dosage. All of these samples were in order. We also checked a sample of residents files for information related to changes in medication. Overall, these were well kept so that we could easily track when and why medication had changed. These changes were implemented accurately and promptly so that residents received their new treatment without delay. We looked at a sample of care plans for managing residents with when required medication such as sedatives and those with complex medication needs. Some care plans contained little guidance for staff to ensure that medication was managed safely and given in an effective manner with appropriate monitoring. In one case the care Care Homes for Older People Page 18 of 39 Evidence: plan for a diabetic resident who persistently refused medication contained little information on monitoring or signs or symptoms that might indicate that medical attention is needed. Another care plan for the management of tube feeding did not give any guidance on how this was to be done safely or the monitoring that was required. There was no information on the administration of medication through the tube and this is regarded as a specialist method of administration requiring specific training. Whilst most medication was administered by a district nurse, care home staff also gave additional doses of pain-killers. The manager failed to show that adequate safeguards were in place to ensure that repeated doses of pain-killers were administered after the appropriate time interval as separate records were kept by district nurses and the care home, and this places the resident at risk of harm. Overall, the storage of medicines was in order. We checked medicines liable to misuse, called controlled drugs, and the records and stock were in order. However, we found that the cabinet used for storage was not attached to the wall in accordance with the amended Misuse of Drugs (Safe Custody) Regulations 1973. This must be addressed and will be checked again at the next visit. A requirement will then be made if this is does not comply with the law. We discussed training of staff in medicines administration. Senior carers had recently received foundation training in safe handling of medication from the supplying pharmacy. We were told that staff had received training in specialist administration of medication, such as to tube fed residents, from the community nurses but there was no evidence that staff had been assessed as competent in the task or that the nurses had delegated the task to them. The manager did monthly checks, or audits, of medication and this ensures that concerns are highlighted and dealt with promptly to keep residents safe. Care Homes for Older People Page 19 of 39 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is an activities programme for people living at Kirksanton but there is a lack of provision for younger adults to have the opportunity to participate in stimulating and meaningful activities appropriate to their peer group. Evidence: We judged the outcome of these standards through observations made during the visit, from survey responses, care plan and activities records and by talking to people on the day both in the main building and the younger adults living in The Mews. The home has an activities coordinator but they were on leave on the day of the visit. There was a programme of activities for people in the main building and we could see staff spending time with the older people and several people were having their hair done by the visiting hairdresser. During the morning staff and people living in the part of the home occupied by older adults chatted and some people read their papers and two ladies were busy knitting. Later in the afternoon we saw people playing board games and dominoes and others engaged on soft ball games. The atmosphere in the main building was calm and relaxed with friendly banter between staff and the older people taking part and seasonal choral music on the CD player. Some people we spoke with felt they had activities to take part in and one told us there is plenty enough going on for me. Some people had been to an arts centre in a town in the Care Homes for Older People Page 20 of 39 Evidence: area to see a musical performance with the younger people living in the main building and were having their Christmas lunch outing with them at a nearby public house. There were several planned activities for all the people living there over the Christmas period including a musical entertainer coming into the home, a visit to a pantomime and six local schools and a nursery coming in to sing carols. There were opportunities for religious observance and once a month the local Vicar came in for a service and communion. The local catholic priest will also visit people if they want this. As the majority of people living at Kirksanton are older adults we judge under these standards but as a significant number of younger adults also live there we must also consider the different standards set out for Younger Adults in making our judgements. We needed to do this as the younger people living there may have different social, occupational and recreational needs to older people who have reached retirement age. To take this into account we looked at the standards concerning lifestyle for younger adults. This examination and assessment includes what opportunities the younger adults have for personal development, opportunities to learn and use practical life skills, promote their independence, take part in age, peer and cultural appropriate activities that are valued and fulfilling and be part of the wider community. The Statement of Purpose for all people using the services provided, under Philosophy of care speaks of being sensitive to peoples ever changing needs and includes spiritual, emotional and social needs. This document is a statement of what the service says it does and what it will provide and so must be accurate in all its statements. It states that programmes of activities are designed to encourage mental alertness, self esteem and social interaction, it also states they offer a wide range of social and leisure activities. We could not find evidence to support that this statement was being effectively put into practice for the younger adults living in the home. There was a lack of commitment being shown to encourage younger adults to be independent, involved in community activities and to achieve their full potential. We could not see from records, speaking to people or our observations that independent living skills are being given importance or that opportunities are being provided to develop them. We could not see or find practical evidence that staff were working with younger adults to help them learn or to develop personally. We found that in both younger and older adults previous interests had been recorded and personal profiles, aspirations and background information had been collected. This type of information is very useful in putting a programme of activities and recreation together with someone to help them live the daily and social life they want but it was not being used and consistently applied in practice. There was no record of group activities in the Mews. There was a wipe clean activities chart but this was smudged and we could not easily read what was planned. Care Homes for Older People Page 21 of 39 Evidence: There was no evidence that younger adults had any different approach to activities provision than the older people living there and none had been able to take an annual holiday over the previous year. There was evidence that people had been out locally to do shopping and visit the local cafe and some were going out to do some Christmas shopping. People told us they enjoyed doing this and that were also able to see their friends and families as they wanted and go out with them as they wished. We spent the morning in the Mews and found that the 7 people living there spent the morning in the smokers room with the television on and going to and from their rooms. One person complained to us about their right to smoke being taken from them in their own home. We saw 3 people all come hourly to get a cigarette and have it lit, although others did have their own. Staff confirmed, when we asked, as there was no recorded evidence, that currently no one in the Mews had any work, paid or voluntary, no one was attending day services, college or training courses or attended clubs or hobbies outside the home. One person told us they had liked to go swimming but had not been able to since the local pool closed and there was a cost element to travelling further afield to swim. Consequently they no longer pursued this interest. We asked about other opportunities for exercise and social inclusion such as using a gym as there was a local one, but again there was a cost element. People do have only a certain amount of spending money available to them but no one was receiving support with practical life skills such as budgeting to help them manage their money to cover more than cigarettes. One person had a history of breathing problems and had visited a smoking cessation clinic but was now smoking again. Some people have conditions that can make taking part socially more difficult and might need programmes of support to re learn some skills or gain confidence to be more independent and motivated to participate in social occasions. There was no evidence of such support programmes. In the grounds we could see a greenhouse but the door was off and some glass broken. Inside were the remains of some tomato plants from the Summer. People told us they had been interested in this. We discussed the differences in lifestyles and social support that may be needed by younger and older adults and that opportunities need to be more diverse and broader consultation upon what these different age groups want. Individual plans can then be developed through working with people in a more person focused and enabling way. The manager must consider the different lifestyle aspirations of the younger adults living in the home and put in place systems to support and enable opportunities for personal development and independence, training, meaningful occupation or voluntary activities and for integration into wider community life. Care Homes for Older People Page 22 of 39 Evidence: We spent time in the dining room in the main building at lunch time and looked at the menu choices available to people. We found that people had been asked their choice before the meal and that lunch time was a relaxed occasion and staff did not rush people with their meals. Where people needed support staff gave this from providing appropriate aids to help people feed themselves to, cutting up food and assisting people to eat. A choice of drinks was offered both hot and cold and vegetables were served individually for people. The surveys people sent us showed satisfaction with the meals in the home and made complimentary comments including, We have a good cook and several told us The food is good. At the last inspection by the environmental health officer the home achieved 4 stars. Care Homes for Older People Page 23 of 39 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Policies and procedures are in place to help ensure that people living at Kirksanton know how to make a complaint or raise concerns and staff have been given the training needed to understand them. Evidence: The home has a suitable complaints policy and procedure, which is made available to people living in the home and their relatives. Survey responses from people living in the home, their relatives and staff working their, confirmed they knew who to speak to regarding any concerns or complaints they may have. Since the last inspection the organisation has reviewed its complaints policies and procedures to try to develop robust reporting processes to help make sure people feel that they can make complaints or suggestions and that any issues will be acted upon. The home has received four complaints in the last year and we examined the records and investigations that resulted. There is a complaints log recording the nature of the complaint, the complainant, actions taken and notes of any statements taken. There were 2 complaints recorded where the corresponding detailed complaints information forms had not been completed showing the investigation and actions taken or when to prevent the situation arising again. The complaints had been dealt with by the manager but we recommended to the manager that they made sure they kept complete complaints records required by regulation so it can clearly be seen that appropriate action has been taken to satisfy all parties involved in making a complaint Care Homes for Older People Page 24 of 39 Evidence: and protect peoples interests. Periodic audits of the complaints would help prevent omissions as well as support quality monitoring. Guardian Care do have suitable policies and procedures in place about safeguarding vulnerable people and they provide staff training. The manager has completed training provided by the local authority to enable her to give this training to staff. According to the homes computer records care staff have been given training on safeguarding people from abuse and recognising abusive situations this year. Staff we spoke with were aware of the policies and procedures and said they would report concerns to the manager. Step by step information is available for staff on the processes involved including making referrals to the protection register. Training records also indicated that training had been provided to staff this year on understanding Deprivation of Liberty legislation and upon the Mental capacity Act that may affect the rights of people living in residential homes. There have not been any referrals made to social services under safeguarding vulnerable adults procedures since the last inspection. The survey responses we received back from people living in the home and their relatives did not indicate they had any difficulty in raising concerns. One person commented I never have any. Since the last inspection the management has taken action to improve the training provided to staff on safe guarding people from abuse and recognising what forms abuse may take and on promoting individual rights. The management needs to continue to support this improvement and monitor its effectiveness to show a sustained record of managing and developing improvement in this area over the long term. Care Homes for Older People Page 25 of 39 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Kirksantom live in a home that is being maintained and is warm and homely but problems with odours and smoking arrangements could undermine the homely environment. Evidence: Kirksanton Care Centre is situated in a rural setting within the village of Kirksanton approximately 2 miles from Millom. The village does not have regular or frequent public transport and is some distance from the railway station. The home does have its own vehicle that staff use to take residents out. There are garden areas that are being kept tidy by the maintenance person and they also attend to the day to day maintenance of the buildings and the testing of equipment to keep it safe for use. Records indicate that they have checked the water temperatures in the home to prevent the risk of scalds and also to prevent the risk of Legionella. The home is divided into three areas. The older part of the house, known as The Croft had no one living there on the day of the visit. We looked around and found that the lounge area in the Croft smelt heavily of paraffin but could not find the origin of the smell. This part of the home had previously had problems with damp but this was not evident at this visit. This part of the building is accessed by a passenger lift but some bedrooms we saw are only accessible after negotiating steps. Some of the bedrooms still contain kitchen equipment. We discussed this with the manager, as Care Homes for Older People Page 26 of 39 Evidence: given the layout of this part of the home and the number of corridors and steps people would need to negotiate, they must be able to show that any person admitted was assessed as suitable for this environment. There were no plans to admit anyone at present and the manager acknowledged that they will need to assess each new admission with the environmental conditions in mind. The main part of the home is known as The Annex and is home for older adults living there, some of whom may have dementia. Some of the bedrooms in this part of the home are of a very good size with en suite facilities. Other bedrooms are smaller and have a wash hand basin. We could see that people had been able to bring in some personal items of importance or value to them to make their rooms more personal and individual. Peoples names were on the doors to their rooms and on their place settings in the dining room. On the day of the visit we did notice some bedrooms had an odour of stale urine and one was very strong and combined to detract from the homely atmosphere in this part of the home. The manager was aware of this problem and was trying to address it. One room was having the carpet replaced with a type of flooring that would minimise the smells arising from urine spillages. A cleaning regime was in place to combat smells arising from incontinence problems but this does not appear to be fully effective. We recommended to the manager to seek more expert advice on dealing with this. The communal and dining areas of the home were warm and well lit and we saw the lounge being used for group activities during the day. The furnishings were generally of good quality, appropriate and in good condition for the people using them. We saw that people used the easy chairs during the day and used wheelchairs where needed to go to the dining room for their meals. Records indicated that the wheelchairs in use are checked weekly to make sure they are in good order. We asked the manager about the heating in the home and if it could be controlled in peoples rooms, which it could. Improvements have been made to the heating systems in the Mews to make sure the home is appropriately heated. The main building known as the Annex is due to have a new heating system installed. On the day of our visit it was warm and homely, although the corridor connecting the Annex and Mews was very cold. The third area of the home is called The Mews and is intended specifically for younger adults with Korsakoffs syndrome, which is a chronic condition. Each person has a flat comprising of bedroom, lounge (with a small kitchen area) and bathroom. The rooms we saw were spacious and light and were suitably furnished and decorated. There is one lounge in the Mews and this is used as the smoking room for the entire home. There is an extraction fan to help with the smoke. People who do not smoke do not Care Homes for Older People Page 27 of 39 Evidence: have access to a non smoking lounge other than their own flat. The manager should consider the provision of a non smoking lounge in the Mews and make sure the arrangements currently in use meet the Local Authority guidelines on smoking rooms and bedrooms to ensure best and safe practice in this respect. There is a kitchen /dining room in the Mews and some people like to eat together. Although the kitchen table is not big enough for everyone to eat at together people do have dining areas in their flats. The service has policies and procedures in place on infection control and written assessments on hazardous substances. Training records indicate that staff have previously been given training on the prevention and control of infection. The homes laundry is outside and away from areas used by the people living there. There is a laundry assistant to do the washing and ironing and people we asked told us they were satisfied with the laundry system. Generally we found the main home and communal areas to be clean and kept tidy and we checked on bed linens and these were clean. Surveys we got back from people living there and their relatives indicated they were satisfied with standards of cleanliness and all those replying thought the home was clean and fresh. One person commented that Its clean and tidy and warm. Care Homes for Older People Page 28 of 39 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living at Kirksanton are supported by staff who know them well but a lack of appropriate training to use some specialist techniques means that some people may not be as safe as they should be. Evidence: We looked at the staff rotas and these indicated that there are sufficient support staff on duty at different times of the day to support the people living there and meet their personal care needs. As current occupancy is low we saw that staff were able to spend some time with people on a one to one basis during afternoon activities. However as levels of occupancy and needs and dependency change the manager should assess staffing to ensure effectiveness in providing person centered care. We recommended to the manager that, although current levels are acceptable they should keep staff levels under review and adjust them in line with any changes in numbers of people living there, their needs and levels of dependency and capability. We saw that the service provides escorts for people attending appointments and these are in addition to the staff on rota so their numbers remain the same. One person was going out to attend a hospital appointment that day with an escort. There are two domestic,staff, a laundry assistant and maintenance and catering staff to keep the houses and grounds tidy and the building maintained and to provide the home cooked meals for people living there. There has been some staff turnover in the Care Homes for Older People Page 29 of 39 Evidence: last year with six staff leaving and new staff have been recruited. We looked at staff training, induction and recruitment records. The service operates an effective recruitment system and provides an induction period for new staff. We looked at staff training and recruitment files and could see that appropriate security checks and references had been obtained before new staff began work there. We saw staff induction training files and supervision records and records of staff training and certificates of qualifications and training. A high proportion of staff have NVQ in care at level 2 or above and this training is well supported. The deputy manager was doing the NVQ level 4 in care and management. The training records we were given by the manager indicated that staff had been given the mandatory training required and staff surveys and responses helped confirm this. The record indicated they had completed mandatory training on manual handling training, fire training at appropriate intervals, food hygiene training and a number of staff with First aid training. However records indicated that most staff had not had updates on infection control and practice for over three years. We recommend that the manager makes sure staff have updates on this important area to make sure staff are up to date with best practice. Records and staff surveys indicated staff were given additional training relevant to their roles including on dementia care, nutrition, the mental capacity act and deprivation of liberty and care planning training. The manager has made improvements in training provision as recommended at the last inspection mainly including safeguarding, managing challenging behaviour and dementia care training. However we found that some care staff were administering some as required medicines to a person via a tube into the stomach. This is called an invasive technique. Specific training is needed by any care staff member administering medicines into a tube into the stomach. Senior carers had recently received foundation training in safe handling of medication from the supplying pharmacy, but this level of training does not cover invasive techniques. We were told by the manager that staff had received training in specialist administration of medication, such as to tube fed residents, from the community nurses but there was no evidence that staff had been assessed as competent in the task or that the nurses had delegated the task to them. We strongly recommended that the manager ensures that any staff who carry out any specialist or invasive techniques have a formal assessment within a clear framework of the competencies needed to do this and that it is made clear that the task has been delegated by the district nurse to specific staff for the individual needing it. Care Homes for Older People Page 30 of 39 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management team at Kirksanton needs to continue to work on management systems so that people who live in the home can be sure it is run in their best interests. Evidence: The home has a registered Christine Munroe who has worked in the home for several years and has previously been the deputy manager. Records indicate she has gained her Registered Managers Award and has undertaken some training since the last inspection to update her knowledge. This includes doing a trainers course with social services on protecting vulnerable adults so she can also train staff in this. She has also done recent training on Mental Capacity and Deprivation of liberty legislation and care planning. However given the complex needs of people living there and especially the chronic conditions and cognitive impairments experienced by some of the younger people living there the manager needs to consider obtaining more specialist training in this practice area. This would help enable her to work with people who have unusual kinds of dementia, implement support programmes and provide clear direction for Care Homes for Older People Page 31 of 39 Evidence: staff on supporting people with chronic conditions to lead lives that can help them achieve their potential and promote independence. The manager is clearly trying to improve the services on offer and take the home forward with the resources she has but needs continued support and training if she is to be able to achieve this over the long term. The manager confirmed that she receives formal supervision and these professional and service development and support needs could be addressed within that process. Staff supervision records and staff surveys indicate that staff are also receiving formal supervision and training and practice issues discussed. We could see from the records held and our observations that training was being given greater importance and more training provided to improve staff knowledge and skills. Our observation, conversations with staff and their survey responses indicated that the manager was approachable, supported her staff and discussed their work with them. However the training records we were given indicated that some staff have not had health and safety training for 3 years and for the manager and deputy not since taking up new roles and responsibilities within the organisation. This should be done to help make sure staff are fully aware of their responsibilities and that the management team are fully aware of theirs since changing roles. We could see from review dates that some policies and procedures had not been subject to regular reviews, some for 3 years. These included those on health and safety, infection control, hazardous substances, fire safety and whistle blowing. All important areas that that need to be reviewed regularly to make sure they reflect changing legislation and good practice. We recommend that the manager makes sure there is a system in place to make sure all policies and procedures are reviewed on an annual basis at least. We checked the fire log and this was up to date as was routine maintenance of equipment and services and the checking and servicing of emergency equipment. We asked the manager for a copy of her most recent Annual Quality Audit and she gave us a breakdown of surveys for 2009 that had been sent out to peoples relatives and health care professionals. These survey results were in both graph and written forms. This showed some very positive responses from relatives. We could not see the results of the surveys on display or generally available so that the people who took part could see the outcomes. The manager told us these are usually in the foyer but they were not on the day of the visit. There are residents meetings being held and these are advertised in advance so people can attend and give their views and opinions. The manager showed us the services Business plan commenced October 2009 and this had plans to address issues identified at the last inspection and generally. Areas such as capital expenditure, occupancy levels, the current market and the services Care Homes for Older People Page 32 of 39 Evidence: perceived strengths and weaknesses were looked at. The manager does some monthly checks on medication, care plans and the premises and provides a monitoring report for head office. This helps monitor quality in these areas. Talking to the manager it was clear there was still some uncertainty about the future use of the older part of the building and so it is difficult for management to always give a clear sense of direction for staff and the focus of best practice. We looked at what was in place to safeguard peoples finances and spending monies kept by the home for people living there. We found that records are kept on computer and hard copy and running totals checked monthly by the manager. There is a system in place for keeping receipts for purchases so there is an audit trail to follow. We could see that the manager is actively trying to develop the service and the staff and needs to continue to do so and provide evidence of sustained and long term progress and consistency with this. Care Homes for Older People Page 33 of 39 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 34 of 39 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 The manager must make sure that care plans are specific and detailed to provide staff with clear guidance and practical strategies on managing individuals specific conditions and behaviour. This will help make sure there are individualised procedures for people focusing on positive behaviour and ability. 12/03/2010 2 12 16 The manager must consider the different lifestyle aspirations of the younger adults living in the home and put in place systems to consult with them and to provide and support them with opportunities for personal development, independence, learning or training and meaningful occupations or voluntary activities and to enable 12/03/2010 Care Homes for Older People Page 35 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action integration into wider community life. This is to help ensure that people will be enabled to take part in a variety of social activities, educational and work opportunities and have lifestyles where they can be independent and achieve their personal potential. 3 30 18 The manager must ensure 25/01/2010 that any staff who carry out any specialist or invasive care techniques have had a formal assessment within a clear framework of the competancies needed to do the task and that it is made clear that the task has been delegated by the district nurse to specific staff for the individual needing it. This is to help make sure that staff have the appropriate training for the work they are to do and protect the health and welfare of individuals. Care Homes for Older People Page 36 of 39 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 We recommend that the manager should consider putting information on what services both, specialist and general, are available to meet the needs and life expectations of younger people thinking of coming to live there. This will help to to make sure they give younger people the most comprehensive information to help them in their decision making. We recommend that the manager looks at providing ways to make the admission process more personalised and focused upon achieving the personal outcomes people wanted. The manager should make sure that assessed nutritional needs and plans give clear instructions and are followed by all staff to make sure people receive the nutrition support they need. It is recommended that the manager introduce a safe system of handling and recording the disposal of medication that has been refused by residents. It is highly recommended that care plans are more thorough and provide staff with clear guidance on managing residents with specific care needs for the administration of complex or when required medication so that they are managed safely and effectively. We recommend that the manager makes sure they always keep complete records of all complaints received so it can clearly be seen that appropriate action has been taken to satisfy all parties involved and protect peoples best interests. The manager should consider the provision of a non smoking lounge in the Mews and make sure the arrangements in use meet the Local Authority guidelines on smoking rooms and bedrooms to ensure best and safe practice in this respect. We recommended to the manager that they keep staff levels under review and adjust them in line with the changes in numbers of people living there, their needs and levels of dependency and capability. We recommend that the manager makes sure staff have updates on infection control to help make sure staff are up to date with best practice in this area to promote the health Page 37 of 39 2 3 3 8 4 9 5 9 6 16 7 20 8 27 9 30 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations and welfare of people living there. 10 31 Given the complex needs of people especially the chronic conditions and cognitive impairments experienced by some of the younger people living there the manager should consider obtaining more specialist training and practical skills in this practice area. This would help enable her to implement support programmes and provide clear direction for staff on supporting people with chronic conditions to lead lives that can help them achieve their potential and promote independence We recommend that the manager makes sure there is s system in place to make sure all policies and procedures are reviewed on an annual basis at least. This is to make sure they reflect changing legislation and good practice. The manager should make sure that all staff are given updates on Health and Safety responsibilities and processes, especially where staff have had a change in role affecting those responsibilities. 11 33 12 38 Care Homes for Older People Page 38 of 39 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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