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Inspection on 10/05/05 for Kirkstall Court Care Home

Also see our care home review for Kirkstall Court Care Home for more information

This inspection was carried out on 10th May 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The inspector spoke to ten service users and without exception they said that the care staff team were friendly and approachable. Service users also said that they enjoyed the organised daily activities and the activities coordinator was clearly a popular member of the staff team. The staff on duty related well to the service users and had a caring and sensitive manner towards them.

What has improved since the last inspection?

The level of training provided to the care staff has improved and care staff were aware of the needs of the service users. National Vocational Training is provided to care staff and they were enthusiastic about training.

What the care home could do better:

The manager must make sure that the pre-admission assessment information about service users is detailed enough to be sure that care needs can be met at the home. Communication between the nursing staff must improve and the manager must make sure that she gives them clear leadership and management. The care plans did not demonstrate that all care needs were being properly identified and dealt with appropriately. Service users were not aware of their care plans and the manager must ensure that they and or their representatives are involved with the care planning process. The lack of suitable door locks on the bathroom, toilet and bedroom doors does compromise the privacy and dignity of the service users and locks should be provided. Requirements and recommendations have been made.

CARE HOMES FOR OLDER PEOPLE Kirkstall Court 119-129 Vesper Road Leeds LS5 3LJ Lead Inspector Catherine Paling Unannounced 10 May 2005 09.15hrs th 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Kirkstall Court Address 119-129 Vesper Road Leeds LS5 3LJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2591111 0113 2257444 Dukeries Healthcare Ltd Care Home with Nursing 48 Category(ies) of Old age (48) Learning Disability Over 65 (1) registration, with number Physical Disability (1) of places Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The place for Learning Disability is specifically for a named service user. The place for Physical Disability is specifically for the service use named in connection with the variation. Date of last inspection 11th November 2004 Brief Description of the Service: Kirkstall Court is a purpose built home, dating from 1991. The current providers have been registered since June 2000. The home provides personal care with nursing for up to 48 service users, both men and women, over 65 and very much serves its local community. Service user accommodation is provided over three floors with a majority of single rooms with some shared rooms available, all of which have en-suite facilities apart from one room on the ground floor. There are two passenger lifts, one of which goes to all floors with the second going to the first floor. The home is on the main bus routes into Leeds city centre, four miles away. It is also close to local shops and post office. The local pub is a short car journey away, close to Kirkstall Abbey and museum. There are seating areas outside the home, which are accessible to service users by means of a ramp. Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the first inspection for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The last inspection of the home was in November 2004. This was an unannounced inspection by two inspectors who spent seven hours at the home. The main purpose of this inspection was to make sure that the home continues to provide a good standard of care for the service users and to assess progress on meeting the requirements and recommendations made at the last visit. The methods used at this inspection included looking at records; observing working practices; talking to staff and service users; and discussion with the manager. Comment cards were left at the home for residents and relatives inviting them to share their views of the home with the CSCI. Any comments received would be shared with the manager anonymously. The manager was also asked to complete an inspection questionnaire providing more information about maintenance, staff training and other issues which she has returned to the CSCI. What the service does well: What has improved since the last inspection? The level of training provided to the care staff has improved and care staff were aware of the needs of the service users. National Vocational Training is provided to care staff and they were enthusiastic about training. Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The pre-admission assessment process does not guarantee that all the needs of residents are met. EVIDENCE: The inspector looked at four service users case files and only one contained a pre-admission assessment. This pre-admission assessment had been done by the manager and was poor with limited information about the service users specific needs. Although the EasyCare Assessment was available this did not contain adequate information either. A requirement has been made for Standard 3. Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10. The information within records and the knowledge of the staff does not indicate that the physical and healthcare need of service users are fully met, potentially placing service users at risk. The lack of locks on bedroom, bathroom and toilet doors compromises the respect and privacy of the service users. EVIDENCE: There are individual files for all service users with care plans providing information about their individual needs however not all those looked at gave enough information about their health and welfare. There was no indication in one case that the service user or her relatives had been involved in the development of the care plan. The daily routine section of the plan was poorly completed and the day and night reports made by the nurses lacked continuity. In addition action had not been taken when concerns had been noted, for example one service user had been constipated and appropriate action had not been taken; this service user also needed regular visits from a chiropodist and although the records noted that it was needed it had not been arranged. Another service user’s care plan had not been reviewed for two months and during that time he had shown some uncharacteristic behaviour. Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 10 When the inspector asked the nurse on duty for additional information about these service users she was not aware of the issues. Two further care plans were looked at and were satisfactorily completed. None of the service users who were spoken with had a real understanding of care plans and felt that it was something that their families would be involved with. Service users said that staff respected their privacy and dignity however, appropriate doors locks had still not been fitted to bedroom, bathrooms or toilet doors. Requirements have been made. Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 The social need of service users are met and they exercise choice in their daily lives. EVIDENCE: Service users said that they enjoyed organised activities each day and observation of the interactions of the activities organiser with the service users showed that she is a popular member of the staff team. On the day of the visit several service users went out to lunch at the local pub accompanied by off-duty care staff. Service users had chosen this outing and said that other outings were arranged taking into account their wishes. During the afternoon the activities organiser was reading a novel to a small group of more dependant service users. Care staff spoke clearly about respecting the wishes of service users including differing cultural needs. Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Complaints are dealt with appropriately. Overall, service users are protected from abuse with the majority of staff aware of adult protection. EVIDENCE: A relative said that she had complained about the standard of food offered to her mother on one occasion. The relative said that the manager had dealt with the complaint promptly and to her satisfaction. The complainant had received a timely, written response to the complaint. Several staff were spoken to throughout the day and all the care staff were aware of their responsibilities regarding adult protection and were clear about what they would do if they felt that a service user was at risk. They were also aware of the home’s whistle blowing procedure. Care staff had received training about adult protection as part of their National Vocational Qualification. The nurse on duty was not clear about what she would do if someone wanted to make a complaint. In addition she said that she was not aware of the homes policies and procedures about adult protection. The nurse said that she would refer problems to the home manager. Recommendations have been made. Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of these standards were assessed during this inspection. However, although service users said they were satisfied with the standard of accommodation they felt that the home would benefit generally from decorating. Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30. The numbers and skill mix of staff were sufficient to meet the needs of the service users. There are good recruitment procedures in place to protect service users. EVIDENCE: There were duty rosters available for all grades of staff and overall there were enough staff to meet the needs of the service users. Care staff were enthusiastic about training and were knowledgeable about the needs of the service users. The annual training plan shows a wide range of training is now provided to make sure that staff have the knowledge to do their job safely and competently. Recruitment records for two recently employed staff demonstrated that there are robust recruitment practices in place at the home. Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 and 38. The manager does not provide clear leadership, guidance and direction to staff to ensure that service users receive a consistently good level of care. This results in some practices that do not promote and safeguard the health, safety and wellbeing of the people using the service. EVIDENCE: The manager has yet to complete the CSCI registration process and some issues were identified during the inspection that may bring into question her ability to effectively manage the home. When the concerns about the care plans were discussed with the manager she said that she was aware of communication difficulties between at least two of the qualified nurses, which she has not addressed. In addition she was not aware of some of the service users’ problems which had been identified but not acted upon at an early stage. Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 16 Meetings are held with staff, service users and relatives and the notes of the most recent meeting with service users, held on 16th March 2005, were displayed in the home. The manager has yet to have training in the home’s quality assurance procedures and so there are no systems for seeking the views of service users and their families about the service and facilities provided at the home. The manager said that the revised polices and procedures were being discussed at supervision sessions with the staff. However, they are not freely available to staff as there was only one set that was kept in the office, which is locked when the manager is not on duty. In addition the manager was not sure whether the new policies and procedures had been finalised. The manager has been in post since August 2004 and there have been no fire drills carried out at the home since then. Requirements and recommendations have been made. Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 2 2 x x x x 2 Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 18 yes Are there any outstanding requirements from the last inspection? 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 3 Regulation 14 Requirement All service users must have a full and detailed assessment of their needs carried out prior to admission. Care plans must detail the action which needs to be taken to ensure that all health, personal and social care needs of the service users are met. There must be evidence of the involvement of the service user and/or their representative in the development of the care plans. Care plans must be reviewed and updated at least monthly.(previous timescale of 23/08/04 and 1/03/05 not met) Records must contain evidence that the health needs of service users are met and are reassessed when necessary.(previous timescales of 23/08/04 and 1/03/05 not met Suitable door locks must be provided for all the communal sanitary facilities and bedrooms to safeguard the privacy and dignity of service users. (Previous timescale of 1/03/05 not met) Timescale for action 5/09/05 2. 7 15 5/09/05 3. 8 13(1) 5/09/05 4. 10 12(4)(a) 5/09/05 Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 19 5. 32 18(2) 6. 33 24 7. 38 23(4)(e) The manager must provide clear supervision and leadership to all staff, including the trained nurses to ensure that they are effective in meeting the needs of the service users. A quality assurance programme must be developed for the home.(Previous timescale 2/05/05 not met) All staff must take part in at least two fire drills, including the night staff.(Previous timescale of4/04/05 not met) 5/09/05 3/10/05 3/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 16 18 33 Good Practice Recommendations Complaints training update should be provided for the trained nursing staff. Adult protection training should be provided to the trained nursing staff. The revised policies and procedures should be made available to staff, service users and their families. Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Kirkstall Court J52 J03 S1350 Kirkstall Court V225070 100505 Stage 4.doc Version 1.30 Page 21 - 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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