Inspection on 19/10/05 for Kirksanton Care Centre

This inspection was carried out on 19th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kirksanton Care Centre 01/12/09

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 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 09/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Kirksanton Care Centre Kirksanton Millom Cumbria LA18 4NN Lead Inspector Nancy Saich Unannounced Inspection 19 October 2005 10:00 X10029.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 Kirksanton Care Centre DS0000057674.V260527.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 and Care Homes for Adults 18 – 65*. 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. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kirksanton Care Centre Address Kirksanton Millom Cumbria LA18 4NN 01229 772868 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) Guardian Care Homes (UK) Limited Mrs Christine Marina Munroe Care Home 43 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (11), Old age, not falling within any other of places category (18), Physical disability (4) Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 43 service users to include: - up to 11 service users in the category of DE(E) (Dementia over 65 years of age) - up to 10 service users in the category of DE (Dementia under 65 years of age) - up to 4 service users in the category of PD (Physical disability under 65 years of age) - up to 18 service users in the category of OP (Older person over 65 years of age not falling within any other category. The main house must not be used to accommodate service users until it has been appropriately refurbished. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commision for Social Care Inspection. The younger adult category PD does not apply to the Mews building, which may accommodate younger adults (DE) only with the exception of the named condition below. Two named service users in the categories of DE(E) (Dementia over 65 years and OP (Older person over 65 years of age) may be accommodated in a double room within the Mews building included within the overall number of registered places. 23/06/05 2. 3. 4. 5. Date of last inspection Brief Description of the Service: Kirksanton Care Centre is owned and operated by Guardian Care Homes Limited. This company have a number of other homes in the United Kingdom. The home is an older house that has a modern extension and connected building known as ‘The Mews’. All three areas are joined to make one larger property. There is a condition on the registration certificate that prohibits the use of the original house. The home is registered to take older people, older people with dementia and younger people with dementia. The company state that this category is for people who have a specific condition caused by alcohol use. Christine Munroe is the registered manager. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted by Nancy Saich and Collette Hibbert. They met with the residents, the staff, a visiting social worker, some relatives and the manager. They looked at all areas of the home, both inside and out. They checked various records that supported what they observed and what was said. This visit showed that there were considerable problems in all areas of the home and that Kirksanton Care Centre is failing to provide good levels of care and services to the residents. What the service does well: What has improved since the last inspection? The manager now ensures that where possible there are two staff who work together with the younger people who live in ‘The Mews’. The manager has started to give all the staff time when she can discuss their work and help them to develop as individuals. The corridor between the extension and ‘The Mews’ now has a carpet and new arrangements have been made that prevent residents from smoking in this corridor. The company has bought small items of equipment for the kitchen. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 6 What they could do better: The home needs to improve the way they check that new residents will fit into the existing groups. They must also stop admitting people who do not fit into the existing categories. They need to apply and pay for a major variation to their registration to accommodate these residents. They also need to rewrite their ‘Statement of Purpose’ and Residents handbook to ensure they explain who they can care for and give details of the raised charges for the newly refurbished bedrooms. The home needs to improve the way they plan and deliver individual care, especially for people who have complex care needs. They need to have a more robust system for gaining support for older and younger adults with dementia, other mental health problems and learning disabilities. The home needs to consider the different needs of each group. They must look at how they help people to make their own choices and how they support people to maintain the skills they still have. They need to be able to show how they help people with dementia to be as in touch with reality as possible. The company need to provide planned and appropriate activities and outings for all their residents. The inspectors also think they need to consider the geographical location of the home and think of creative ways to ensure people are part of a wider community. Guardian Care must find ways to recognise and address the concerns that were expressed by residents (and staff and visitors) about the environment, activities and future planning. The company need to make sure that their policies, procedures and staff training are strengthened so that the vulnerable adults who live at Kirksanton are protected from actual or potential harm. Guardian Care and the registered manager need to look at the problems related to the internal and external environment. These problems relate to general good housekeeping issues, site management issues and the decor and maintenance of all areas of the building. Residents did not have a comfortable or homely environment and many of them were unhappy about the state of the home. Several people said on the day “it’s a bit like living on a building site”. A number of residents wondered when their bedrooms would be redecorated or new sinks installed. There were six newly refurbished rooms but no one could afford the £500 per week that the company was asking them to pay. One person said they had been promised “ a lovely new room with a toilet …but I don’t think those can be for me…”. Staff were trying as hard as they could to work with the different groups in the home but they had problems understanding the needs of people with complex disorders. Staff needed direction, development and training to meet the specific needs of the residents. The systems in place for managing the home and ensuring that residents get good quality care and services were not working well. The manager and the company need to look at all of these systems and make sure that they are working properly to make sure that residents are getting everything they need and are safe. They also need to look at the fact that the home is failing to meet thirty seven different legal requirements. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 7 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. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 The home has failed to find out the needs of prospective new residents and this has led to people being admitted who they cannot care for properly. EVIDENCE: The manager said that there had been some revisions made to the residents’ handbook but this did not include the increased charges for the newly refurbished rooms. This charge of £500 per week needs to be acknowledged in the documents that go out to prospective residents and to current residents who want to live in improved conditions. The home has admitted people who do not have dementia, but have other mental health problems. The staff team are struggling to understand the needs of these people. There are also a number of people who have other needs but are considered to only have a physical disability. There are six people without Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 10 dementia who are under sixty-five but the home should only take four people in this age range. The company has been asked to deal with this and it is now vital that they address this problem. Residents whose needs have changed have not been referred to a social worker or other professional who could help them to plan their future. Some people may no longer need to be in the home but this hasn’t been considered. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10 The home is not managing to meet the complex needs of the residents and this is affecting the well being of all of the residents. EVIDENCE: The inspectors looked at a number of plans that outlined the personal and health care needs of the residents. They also spoke to these people and checked on how the staff gave them care. Some of these ‘care plans’ were quite detailed about personal care needs and had been recently updated. Other plans were out of date and failed to identify mental or physical health needs and gave no clear directions for staff. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 12 One resident’s plan noted how important good grooming was to his wellbeing but there was evidence to show that this was not happening. Another person was in the home for rehabilitation but the plan was not specific enough for staff to do this well. Other plans didn’t show how to deal with physical, psychological or mental health needs. Residents did receive visits from health care professionals but there was no evidence that things were in place to prevent ill health. Staff spoken to were unable to identify any on-going health care planning for the residents or understand why this was needed. Staff did treat the residents with patience, kindness and respect and were trying to manage the complex needs of people as best they could. They were lacking in guidance and training and felt they weren’t sure how to move things forward. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The arrangements for residents to have a rich and full lifestyle are poor and some residents felt isolated and bored. EVIDENCE: This home has several distinct resident groups but no real feel of specific work being done with different groups or individuals. Some residents said they got up when they wanted and did as they wished but there was no sense of staff supporting people in making the best choices in their daily lives. One or two younger people were helping out with chores and were trying to be a little more independent. Other people who had been admitted with the Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 14 understanding that rehabilitation would be the focus of the care did not have a plan that addressed this need. A number of the younger men spent a lot of their time smoking in their flats or in the activities room. Staff weren’t sure how to motivate these residents. There were no individual activity plans for residents. One person was paying for classes (and transport) out of the home because they were bored. There was no evidence to show that there were activities that were beneficial for people with dementia. Staff were not sure about the type of activities that were best for people who had memory problems. Several residents had partners but their care plans didn’t show how staff should help people to maintain these personal relationships. There were no plans and no opportunities for residents to make new relationships outside the home. Care plans did not discuss residents’ sexual or emotional needs. Some residents said they did get visitors and one family member was spoken to. Some visitors do find it difficult to actually get to the home. Residents find it a problem to travel from the home. A recommendation is made that the home looks at this problem of transport and accessibility. There had been some residents meetings held but the younger people weren’t sure what was discussed and there were no minutes available on the day. There were no formalised structures to include residents or their families in the running of the home. Some residents had been involved in reviews of their care with the home, their family and social workers. Other people had been in the home for a long time and had unmet needs that they were trying to meet on their own. Residents weren’t very assertive about their needs and staff weren’t sure about how they could help them although they did want to support them as much as they could. Residents said the food was very good and one of the inspectors had a pleasant lunch with the residents. The residents said they had choice at meal times and thought the cooking was of a good standard. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The arrangements for residents being protected and having a voice are being poorly managed. EVIDENCE: The home does have a complaints procedure but residents were not confident about complaining. Younger adults were unhappy with the lack of activities they had been promised and some of the older adults were unhappy that they had been offered a nice new room but had then been asked to pay a lot more for the privilege. Some people were unhappy with the poor décor and furnishings but no one had been able to make a formal complaint. Staff have not had training on mistreatment or how to protect vulnerable adults. Staff were unsure about how to protect different residents and had only a vague understanding of how risk could be different for people with dementia and people with learning disability or mental health problems. There was no evidence in care plans to show that risk management to prevent adult mistreatment was being followed. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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 26 The residents live in a very poor environment that does not promote safety or well-being. EVIDENCE: The home is set in a very rural location and there is no public transport to the site. The home does not have any transport available for residents. The home is set in its own grounds. On the day of the inspection the drive and car park were muddy, rutted and pot holed. There was a skip full of rubble and Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 17 broken furniture outside. There were piles of timber and other discarded building materials around the garden. The company had installed a new septic tank. The top of this, although closed, is visible and could be reached by residents The older part of the property is not used by residents but was checked on the day. There were a number of health and safety issues seen in this part of the property. The fire safety matters are dealt with later in the report. This part of the building is still uninhabitable and the condition of registration (that it may not be used by residents) is still current. There is no heating, electricity or services in this part of the building. One room was being used to store paint and other builders materials. The front hall was full of equipment and bagged up old linens and clothing. The extension now has six rooms that have been refurbished to a very high standard. These ensuite rooms were all vacant as the manager said they would only be let to residents who could pay £500 per week. Several residents said they had been offered these rooms then asked to pay the ‘top up’. They were unhappy about this as currently their rooms are not ensuite and have not been redecorated or refurnished for some years. Bedroom sinks were cracked and the surrounds chipped. Wallpaper was peeling from the walls and plaster chipped in some rooms. Several residents were sleeping on old, metalframed hospital beds. Bedspreads were worn and frayed. The inspectors and the residents watched as new furniture, curtains and bedspreads were delivered to the locked new rooms. Residents cannot lock their rooms to secure their possessions. One unlocked empty room had furniture piled up precariously and cupboards and sluices could not be locked. A requirement is made about the provision of locks. There were several bedrooms where the resident did not have an easy to reach lead from the call bell. Staff said these people did not use or want leads. The lounge and hallways were poorly decorated and furnished. The woodwork is scored and gouged all around doorframes. Bathrooms and toilets need redecorated and new sanitary wear installed. Residents did think the dining room was nice and this room was of an acceptable standard. ‘The Mews’ activities area was being used as a kitchen and a smoking room. Tiles were falling off the sink area and the carpet stained and dirty. The room was very smoky and the décor was stained with nicotine. Residents are also smoking in their rooms. The manager said there were plans to decorate all areas of the home in the future. The company had also told the lead inspector this but she has not received a written plan of how this was to happen. There was equipment for residents who had mobility problems but the ‘stand aid hoist’(to help people get up from a chair) was stored, uncharged in a bathroom. A bath seat and a slide board for a resident who had come for rehabilitation were still in their boxes. The home was being cleaned on the day but the poor state of décor and previous building work meant that the environment was dusty and less than Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 18 fresh. There was a smell of stale urine in several parts of the building and this might be due to carpets needing replaced. The whole building was shabby and untidy. Residents felt it needed a good spring clean and redecorating. There had been no attempt to make the environment suitable for people with dementia. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The staffing arrangements are poor and this leaves residents unsafe and without the best care and services. EVIDENCE: The inspectors saw the last four weeks of rosters and there had been some improvement to the way staff were being used to cover the shifts. Some staff were still unhappy that their hours had been cut and the manager was spending twelve hours a week doing care tasks. The mix of experience and training in the staff team was reasonably good but was focussed on the care of older people. Several people had a qualification in care but there was a problem in that the home had admitted people with needs that staff had not been trained to understand or work with. This meant that the staff weren’t equipped to deal with the needs of all of the residents. The inspectors looked at the recruitment file for a new staff member. The check about criminal records had not been returned but this person was seen working alone in all areas of the building. This person needs to be supervised at all times until the full check comes through. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 20 At the last inspection the home was asked to give staff specific training in a range of things (mental health, mistreatment, learning disability and managing difficult behaviour) to meet the needs of the residents. This had not happened. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33,34,36,37,38 The management systems in this home are poorly organised and do not ensure the safety and well being of residents. EVIDENCE: Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 22 There was evidence to show that the company and the registered manager were unsure of how this home should move forward. There had been only three of the twenty-two required actions dealt with from the last inspection. Those that centred on forward planning and developing staff teams were largely unmet. They had not addressed the problem of residents who were out of the registered categories There was no quality assurance system in place and the manager couldn’t find the minutes of the meetings she had held with the younger adults. The lead inspector had asked for a full business and financial plan but this had not been received. The company had sent an action plan about refurbishing the home but had decided to change these. No new plan was available on the day. The manager said she didn’t have an up to date monthly budget statement that she could share with the inspectors. Despite the obvious failings in the management systems the manager was still working twelve hours per week as a carer. A new requirement was made that the manager spends all her hours to the management task. The manager had given every member of staff their first supervision session and staff said they had enjoyed this and were keen to further their own development. The manager said she didn’t get formal supervision. There had been only one recorded visit by a representative of the company since the last inspection. These visit reports should be completed monthly and should give the manager, the company and the inspector an idea of what was happening in the home. The manager’s office was untidy and there were a number of records that could not be found. Residents’ case notes were disorganised and difficult to follow. Fire safety was poor in the home. The fire logbook was checked and was found to have a number of missing records. The fire risk assessment was inaccurate and there were large piles of combustible materials stored in the old house underneath a wooden staircase. Paints and other flammable materials were also being stored here. Carpet cleaning fluid was being stored in the unlocked linen cupboard. Chemicals and a ‘sharps box’ were in the unlocked sluice. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 23 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 2 X 3 1 4 1 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 1 14 1 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 ENVIRONMENT Standard No Score 19 1 20 1 21 2 22 2 23 X 24 2 25 2 26 1 STAFFING Standard No Score 27 1 28 X 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 1 33 1 34 1 35 X 36 3 37 2 38 1 Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes 19 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 1 Regulation 4, 5 and 6 Requirement The statement of purpose and residents handbook must be rewritten with a fuller description of the categories of residents accommodated and a statement of charges for the accommodation provided. All prospective residents must have a full multi-disciplinary assessment of need prior to admission. The registered person must ensure that all the residents in the home come within the registered categories of the home’s registration. Residents care plans must give full details of residents needs and the strategies staff need to follow to ensure good standards of care The registered person must ensure that all residents receive appropriate health care including psychiatric care. All residents must receive appropriate support in social, recreational and leisure pursuits All residents must be helped to DS0000057674.V260527.R01.S.doc Timescale for action 16/12/05 2 3 14 (1), (2) 31/08/05 3 4 14 (1) and 12 (1) 31/08/05 4 7 15 31/08/05 5 8 13 (1) (b) 31/08/05 6 7 12 13 16 (2) (n) 16 (2) (m) 31/08/05 31/08/05 Page 25 Kirksanton Care Centre Version 5.0 8 9 14 16 12 22 10 18 13 (6) and 17 11 18 13 (6) 12 19 23 13 14 19 19 23 (2) (o) 23 15 20 23 (2) (g) 16 17 21 22 23 (2) (j) 23 (2) (c) 18 24 23 (2) & 16 (2) (c) maintain personal, family and social relationships Systems must be put in place to allow residents more choice and control over their lives The company and the registered manager must ensure that residents’ complaints are taken seriously, formalised where possible and acted upon. The policies and procedures of the home must be reviewed to include details of arrangements for the protection of vulnerable adults. Arrangements must be in place for training all of the team in recognising and dealing with adult protection issues. The company must forward details, including timing and costs for the refurbishment of the residents environment by the due date A fence must be placed around the septic tank. The registered person must ensure that residents cannot access any area that is still subject to building work. The registered manager must review the use of shared living space in ‘the mews’, making sure that there are suitable facilities for the activities of daily living. All bathrooms and toilets must be decorated and upgraded with new fixtures and fittings. The company and the registered manager must ensure that residents have access to all the specialist equipment that they need. There must be at least six bedrooms available for existing residents that have been DS0000057674.V260527.R01.S.doc 31/08/05 16/12/05 31/08/05 31/08/05 15/08/05 16/12/05 16/12/05 16/12/05 31/01/06 31/01/06 16/12/05 Kirksanton Care Centre Version 5.0 Page 26 19 24 20 25 21 26 22 27 23 29 24 30 25 26 30 31 27 32 decorated and refurbished with good quality fixtures and fittings. 13(4),16(1) The company must review the & 2(c) provision of suited locks for individual bedrooms, sluices and cupboards 16 (2), 23 The registered person must (2)(p) ensure that all radiator guards are suitable for the purpose of protecting residents from the danger of contact with hot surfaces 16 (2) An action plan detailing the steps taken to ensure good standards of housekeeping are in place must be provided by the due date. 18 The company and the registered manager must ensure that at all times there are staff on duty who are aware of the needs of the different resident groups. 19 Staff without enhanced Criminal Records Bureau checks must not be allowed to work alone with residents 18 (1) (c) A revised training plan must be provided showing how staff will be trained in understanding the needs of people with learning disabilities and the needs of people with functional and organic mental illness. 18 (1) (c) It is required that staff receive training in how to manage challenging behaviour 10 (1) The company must ensure that the manager dedicates all her working week to the task of managing the home. 10 (1) and It is required that the company 21 and the registered manager ensure that there is a new focus on management planning which involves all stakeholders of the home. DS0000057674.V260527.R01.S.doc 16/12/05 15/08/05 15/08/05 16/12/05 16/12/05 31/08/05 31/08/05 16/12/05 16/12/05 Kirksanton Care Centre Version 5.0 Page 27 28 29 33 34 24 25 30 31 36 34 18 (2) 25 (1) and (2) 26 32 37 33 34 38 38 16(2)(g), 23(2)(c) 13 (4) 35 38 13 (4) 36 38 23 (4) A full quality assurance review with an action plan must be produced by the due date The company must provide the inspector with up to date accounts of income and expenditure for the home. The manager must receive formal, recorded supervision. A revised business and financial plan for the six months from 1st September 2005 must be received by the due date A representative of the company must visit unannounced every month to report on the operation of the home. The report must be forwarded to the inspector. The registered person must forward plans showing how the kitchen will be upgraded. The arrangements for controlling materials hazardous to health must be reviewed and all chemicals locked away. The home and the grounds must be cleared of all items of equipment and builders materials that are no longer needed on the premises and the drive and car park levelled and repaired from the damage done by the building work. A review of the fire safety, in line with the recommendations of the fire officer, must be in place by the due date. 31/08/05 16/12/05 16/12/05 31/08/05 16/12/05 16/12/05 16/12/05 16/12/05 31/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000057674.V260527.R01.S.doc Version 5.0 Page 28 Kirksanton Care Centre 1 2 Standard 19 22 It is recommended that the home provide some form of transport for residents. It is recommended that extension leads for the call bell system are available in every room. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Kirksanton Care Centre DS0000057674.V260527.R01.S.doc Version 5.0 Page 30 - 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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