Inspection on 30/05/07 for Kirksanton Care Centre

This inspection was carried out on 30th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 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 09/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Kirksanton Care Centre Kirksanton Millom Cumbria LA18 4NN Lead Inspector Nancy Saich Unannounced Inspection 30th May 2007 9:00 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.V331252.R01.S.doc Version 5.2 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.V331252.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirksanton Care Centre Address Kirksanton Millom Cumbria LA18 4NN 01229 772868 01229 774015 enquiries@guardian-care.com None Guardian Care Homes (UK) Limited 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) Mrs Christine Marina Munroe Care Home 35 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (13), Learning disability (1), Learning disability of places over 65 years of age (2), Old age, not falling within any other category (12), Physical disability (5) Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 35 service users to include: up to 13 service users in the category of DE(E) (Dementia over 65 years of age) 1 named person in the category 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 5 named service users in the category of PD (Physical disability under 65 years of age) up to 12 service users in the category of OP (Older person over 65 years of age not falling within any other category. Up to 2 named service users in the category of LD(E) (Learning Disability over 65 years of age) 1 named person in the category of LD (Learning Disability under 65 years of age) 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 Commission for Social Care Inspection. The mews building may only be used to accommodate younger adults with dementia - apart from one named person in the category DE(E) as shown above. 16th October 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Kirksanton Care centre is owned by Guardian Care Homes. A new manager is in the process of being registered. Guardian Care Homes own a number of other residential and nursing homes in England. The home has three distinct areas. Residents do not occupy the older part of the property. The dining room, main lounge and bedrooms are in the modern extension to this older property. The Mews building is connected to this central part of the home. The Mews is set out as self-contained apartments with their own lounge/kitchen, bedroom and bathroom. Younger people with a diagnosis of alcohol related dementia (Korsakoff’s Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 5 syndrome) live in this Mews building, while older adults, older people with dementia and younger people with physical disabilities live in the main part of the house. Information about the service can be obtained from the home or from the providers website. Charges for care are as follows Older Adults -£363 per week Older Adults - High dependency -£385 per week Older Adults with dementia - £422 per week People with a mental health disorder - £353 per week Younger Adults with dementia - £531 per week Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was the ‘key’ or main inspection for the year. The home has had two other ‘random’ inspections (where not all standards are checked) since the last key inspection in October 2006. These random inspection reports (31/01/07 and 24/04/07) are in the form of letters to the provider. Copies of these can be obtained from the Penrith area office. The inspector sent out surveys to residents early in the year and had a good response. She has also asked the new manager and the company for information and has had prompt responses to these requests. On the 30th May Nancy Saich, the lead inspector arrived at the home with another inspector – Margaret Drury just after nine in the morning. Penny Wilkinson – Regulation manager, joined them a little later. They met all of the residents and spoke to some of them in depth; they spoke to staff on duty and to the management team. They read files and documents that backed up what they saw and what was said to them. This home has seen a steady improvement in the last six months and the inspectors look forward to all these changes being consolidated and to further improvement being put in place. What the service does well: Residents enjoyed the food provided and the inspectors judged that catering systems were working well. The home provides comfortable and well-decorated bedrooms and lounges for residents. The accommodation has good quality furniture and fittings. The grounds are spacious and well tended. One person said: • ‘I like my own room and spend a lot of time there but also like to get out to walk around the garden.’ Guardian Care provides suitable training for staff so that they have the basic skills and knowledge they need. They also provide enough support for people to gain National Vocational Qualifications in care. They only take on staff after they have checked that they don’t have a criminal record and haven’t been dismissed from another care setting. The home has a good system in place to make sure that residents are asked about their opinions on the quality of care and standards provided. They have used it to make changes. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The manager and the senior staff need to make sure that everyone on the staff team work together on the care plans so that the good practice on paper is seen in the care, services and activities offered to the residents. They also need to develop specialised activities for people with complex needs. These must meet their cultural and social needs and help with lifestyle choices, be age appropriate yet also support their care needs. Staff need to improve Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 8 their skills and knowledge around the care of people who have alcohol related dementia. Guardian Care needs to make sure there are always enough carers on duty during the day so that not only basic care but also outings, activities and specialist individual and group work can be provided for all residents. One of the doors and ramps into the enclosed garden needs to be made safe and secure. This door needs to be alarmed in to the call-bell system. 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. The summary of this inspection report can be made available in other formats on request. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 9 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.V331252.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home is now making sure they only take new residents that they can care for and who will fit into the rest of the group. EVIDENCE: The inspectors checked on the files of the most recent residents to come to the home. They found that the manager or his deputy had done thorough assessments. Residents said they had visited the home. Staff said the management were much better at taking in the kind of residents they could care for. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 11 A number of residents have had social workers look at their needs. In some cases it was agreed all round that their needs would be better met in a different setting. The manager was very aware that getting the right mix of people was important to residents well being. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is working on improvements to the kind of care that will meet the very complex and diverse needs of residents. EVIDENCE: The inspectors read approximately half of the residents’ files. They spoke to the people involved and also observed how they were being cared for. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 13 They discovered that in many cases they had good written plans that help staff to give people the care they want and need. Everyone’s plans were up to date. Some plans still need a little more work but generally they showed promising improvement. These plans included details of health needs. The inspectors saw some examples where the manager and his team had worked really hard to get the most up to date care and attention for the residents. This had improved people’s health. They checked the medicines kept on behalf of residents and found these were being ordered, given out and recorded in a much more precise way. They saw that a good effort had been made to reduce sedative medicines. They discussed the use of these with senior staff and were pleased to find that they were trying to talk to the G.P about reviewing people’s medicines. The inspectors saw staff working well with residents on this visit. They had found during the random visits that some staff didn’t always ensure peoples privacy and dignity were being met. They were pleased that the manager has this as a high priority with staff and the inspectors recommend that the team work together to continue to improve this. They judged that they now need to make sure that everyone follows the care plans to help with things like independence and choice, responsibility and rights, dignity and privacy. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for social, recreational and therapeutic activities are being actively worked on to improve quality of life for everyone. EVIDENCE: The inspectors met with the activities organiser and spoke to the staff team and to the manager. The home now has transport and people said they were going out more. Contact has been made with specialist teams for learning Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 15 disability and they are going to help with suitable activities. The manager is trying to make contact with agencies that can help in a similar way with people with alcohol related dementia. The inspectors heard about plans for social activities and contacts with local groups and thought these were good and would improve the lifestyle for residents. They also want the staff team to think about ways to improve the routines of the day –just so people would get even more choice than they already have. They judged that although a good start had been made on improving activities for younger adults there was a lot more to be done to really provide the specialist care that these people need. They are aware that major projects like this take time to develop and time for residents to get used to. They will check on this again at the next visit. They were pleased to see that the new manager is working with the cooks to make the menus even more nutritious and age appropriate. They look forward to seeing the kitchen staff being more involved with the full care of residents. They also felt that nutritional planning had improved and had the potential to really help people be as well as possible. They saw people being helped to eat in a very nice way and this too was an improvement on the way things had been. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team are much more aware that they need to listen to people and protect them from harm. EVIDENCE: The inspectors saw the record of complaints and found that some minor matters had been dealt with properly and that this had prevented the concern developing into a major complaint. Residents said that they could speak up if they were unhappy. A number of people felt they were being listened to more and that there was more scope to talk to people outside of the organisation. Earlier in the year there had been a number of problems that might have put residents at risk. However the company had reported these matters and had put things into place that lessened the risk. There had been no further issues of concern after these changes. Staff had received training and had been reminded of their responsibilities and they were confident about how to prevent abuse and how to report any concerns. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. This home provides a comfortable environment where residents are beginning to feel relaxed and safe EVIDENCE: The inspectors walked around the home and looked at shared areas and bedrooms. They also looked at the main kitchen. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 18 They found the home was cleaner and tidier than it had been in the past. Both inside and out there things were much more orderly and this meant that the environment was safer for people in the home. The team had dealt with an odour problem and this made the home a much more pleasant place to be in. there were good systems in place to make sure the home was clean and hygienic. Residents were happy with their bedrooms, saying they were comfortable and when the inspectors walked around the home they could see that people were very relaxed in their own rooms. The residents in the Mews enjoyed having their own bathroom, lounge and bedroom and some people use the kitchen facilities in these ‘apartments’. The lounges and dining rooms were well decorated and furnished and residents said they enjoyed using these shared spaces. The kitchen was clean and well ordered but there were one or two areas that still need updating. The lead inspector accepted that this will be looked at later in the year and will check on it during future inspections. There was one problem with an ill-fitting (but rarely used) door and ramp into the enclosed garden. This door is not alarmed. The manager said that this would be done along with the planned upgrade. The inspectors judged that there could be a risk here and they have extended the existing requirements. Once this work has been done all the requirements about the environment will have been met. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Improvements to staffing arrangements would make the improvements to residents lives much more achievable. EVIDENCE: The inspectors were pleased to note that there had been an increase to staffing and there was now one extra person on most evenings. They also judged that the major work on the roster has really changed things in the home. The staff now work both day and night shifts and they said that this helped them understand all aspects of the residents’ lives. The inspectors did think that there were times in the home when there was still not enough staff on duty. For example when one or two people in the Mews need a lot of care other residents may not get the level of attention and activities they need. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 20 They want Guardian Care to make sure that there are always two members of staff in the Mews. Currently staff from the Mews are used to help with the older adults in the main house. This practice can spread staff too thinly on the ground. A number of people in the main house need a lot of supervision. The inspectors judged that extra hours need to be put into the main house at busy times. The manager needs to address this without taking staff away from the people in the Mews. The inspectors spoke to staff and found out that they had received training on dementia care, protection of vulnerable adults, managing change and dealing with medication. Several people were working on their National Vocational Qualifications and many others had the award. The inspectors saw a good training plan in place to show that the company were going to provide further training. They also saw some localised training for staff to help them work with people with learning disabilities. The staff team still need to work on their skills and knowledge around the needs of people with Korsakoffs’ syndrome but the manager had started to work on this. The inspectors checked on the latest recruitment to the home and this had been done correctly and with the appropriate checks in place. This ensures the home only employs people without criminal convictions or who haven’t been dismissed from any other care job. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35,36 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 22 Once the new manager has time to develop and consolidate all the plans he has the home will provide residents with the kind of management that will promote wellbeing and safety. EVIDENCE: The home has a new manager who has been in post since January. He still needs to become registered with the Commission for Social Care Inspection. He is already showing that he is proactive and enthusiastic. Staff and residents were very positive about him. He was very realistic with the inspectors and was aware that there is still a number of improvements to be made and that these changes need to be consolidated over the next few months. He was aware that he must work on all the systems that ensure the delivery of the best care and services. The inspectors look forward to seeing that consistent care is delivered, that individual and group activities are appropriate for the diverse needs of residents, that the daily routines are reviewed and that the deployment of staff is managed in a way that encourages good outcomes for residents care. Guardian Care has a suitable Quality Assurance system in place and they have been using it to work on improvements. The inspectors will continue to check that this is an active system and look forward to seeing their next full audit. Residents cash held on their behalf was checked and it balanced with the accounts. The inspectors learnt that the manager was trying to open individual accounts for residents so that residents can be more independent. The inspectors looked at staff supervision records at the last three visits and they discovered that the deputy manager has really started to develop this formal system that helps staff to develop in their roles. A lot of records had been looked at during the last few visits. These are much more organised and this has helped things to run more smoothly. There had been two problems that might have compromised the safety of staff and residents alike. These had been dealt with by the company very quickly. Health and safety systems were operating well and no hazards were seen on the day. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 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 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 3 34 X 35 2 36 X 37 X 38 3 Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 (2) (b) Requirement The registered manager must make sure that the home is safe and well maintained at all times. This requirement has been extended until one door has been repaired or replaced. Two staff must be available from 8 a.m to 8 p.m in the Mews and additional hours must be provided at busy times in the main house. Timescale for action 31/07/07 2. OP27 18(1a&b) 15/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP10 Good Practice Recommendations It is recommended that the manager continues to work with all the staff to ensure they always follow the details of the care plans to give residents holistic care. It is recommended that the manager continue to work with staff to ensure that all residents get care that meets their rights to dignity, privacy and independence. DS0000057674.V331252.R01.S.doc Version 5.2 Page 25 Kirksanton Care Centre 3 OP12 4 5 6. 7. 8. OP13 OP14 OP19 OP30 OP31 9. OP35 It is recommended that the manager and the staff team help the residents look at all the routines of the day and continue to work on providing activities to give residents a suitable lifestyle. The manager needs to keep working with local networks to give the residents wider social contact and as much support as possible with external organisations. It is recommended that staff look at new ways to help residents maximise personal autonomy and choice. This ought to reflect their age and social and cultural needs. It is recommended that Guardian Care provide an alarm to the garden door so staff will know when someone uses the enclosed garden. It is recommended that the manager continues to search out specialists who can deliver training to staff about people with alcohol related dementia. It is recommended that Guardian Care continue to give the manager enough support to ensure he becomes the registered manager and that he can put his plans into action. It is recommended that Guardian Care work on finding a way to help residents open their own individual bank accounts. Kirksanton Care Centre DS0000057674.V331252.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V331252.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!