Inspection on 02/11/05 for Kirkstall Court Care Home

This inspection was carried out on 2nd November 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

Kirkstall Court Care Home 09/02/09

Kirkstall Court Care Home 05/03/08

Kirkstall Court Care Home 04/09/07

Kirkstall Court Care Home 11/09/06

Kirkstall Court Care Home 10/05/05

Kirkstall Court Care Home 11/11/04

Kirkstall Court Care Home 22/04/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Kirkstall Court Care Home 119-129 Vesper Road Leeds Yorkshire LS5 3LJ Lead Inspector Catherine Paling Unannounced Inspection 2nd November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kirkstall Court Care Home Address 119-129 Vesper Road Leeds Yorkshire LS5 3LJ 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) 0113 2591111 0113 2257444 Dukeries Healthcare Limited Care Home 48 Category(ies) of Learning disability over 65 years of age (1), Old registration, with number age, not falling within any other category (48), of places Physical disability (1) Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The place for LD(E) is specifically for a named service user. The place for PD is specifically for the service user named in connection with the variation application dated 25.6.4 10th May 2005 Date of last inspection 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 route 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 Care Home DS0000001350.V259759.R01.S.doc Version 5.0 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 second 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 May 2005. This was an unannounced inspection by two inspectors who spent six 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. What the service does well: What has improved since the last inspection? The level of training provided to the care staff continues to improve and staff are enthusiastic about training. Attempts have been made to involve residents and relatives in the development of their care plans. Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 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 Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. (Standard 6 is not applicable). Residents have their needs fully assessed before moving into the home and are assured that these can be met. EVIDENCE: Residents have their needs assessed prior to admission. The revised preadmission assessment format provides information about care needs and information about who carried out the assessment, who was involved and where it took place. The pre-admission assessments seen were carried out to a good standard. Letters were also seen from the manager to the prospective resident and their family confirming that care needs could be met. Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 10. Care plans are poor and, although health care needs are met overall, the lack of detail within the records provides the opportunity for needs to be overlooked. Medication practices are safe. The continued lack of locks on bedroom, bathroom and toilet doors compromises the respect and privacy of the service users. EVIDENCE: A sample of three individual resident records was looked at. Care plans had been developed in all cases but the information within the care plans was not always sufficiently detailed to make sure that all the health and personal needs of the residents are met. For example, the instructions for one resident’s personal hygiene needs were vague ‘assist with bath or shower once or twice a week as required’ with no detail about the preferences of the resident. In the case of another resident there were instructions to make sure that the correct incontinence pad was worn but no information as to the exact type of pad. Care plans were not evaluated as to their effectiveness. Risk assessments were carried out but the relevance of some was questionable. For example, a risk assessment for the use of bed safety rails Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 10 had been carried out every month for one resident when they were not needed. In another case the home’s risk assessment indicated that bed safety rails were not needed but they were in use, at the request of the family. Those at risk of developing skin damage did not have detailed care plans in place about how to manage the risk. It was also noted that issues identified in the daily records had not generated a specific plan of care. There was no evidence of reviews taking place and one resident had not had their needs re-assessed following a hospital stay. There was some evidence that relatives had had some involvement in the development of the care plans. There was also evidence of general practitioner visits as well as the involvement of other healthcare professionals. The new manager had reviewed the medication arrangements and had addressed overstocking of some items. A senior member of the nursing staff takes the lead in carrying out regular audits of the medicines. Residents feel that staff respect their privacy and dignity. However, the privacy and dignity of residents continues to be compromised as the fitting of door locks has yet to be completed. Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 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 the following standard(s): 13, 14 and 15. Residents’ choices are respected and contact with family and friends is encouraged. A good varied and nutritious diet is provided taking into account individual choices. EVIDENCE: Visitors are welcomed at the home and residents are encouraged to maintain contact with family and friends. Trips are arranged into the local community. The notice board included information about seasonal activities and events. Residents are encouraged to exercise choice over their daily lives with staff committed to encouraging this. There is a four week menu which appears to provide the residents with a varied and balanced diet. Discussion with the cook indicated that she is aware of the individual residents’ likes and dislikes and caters for them accordingly. Residents are involved in the menu planning through the resident/relatives meetings that are held throughout the year. Residents can have breakfast in their room if they wish to do so, however all other meals are served in the dining room. The residents described the food as very good and confirmed that alternatives to the main menu were offered at all meal times. Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 12 The lunchtime meal was unhurried and members of staff were observed to assist/prompt residents to eat in a sensitive and appropriate manner. A bowl of fresh fruit was available in the dining room for the residents to eat as and when they wish, and the cook confirmed that hot and cold drinks are freely available throughout the day. The kitchen was inspected by the Environmental Health Department. On the day of the inspection the standard of hygiene and cleanliness in the kitchen was found to be good. Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these standards were assessed at this inspection. Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. The home requires extensive refurbishment. Some practices create the opportunity for cross infection, potentially placing residents at risk. EVIDENCE: Internally the home appears shabby with damaged paintwork and requires extensive refurbishment. A planned programme of refurbishment work must be submitted to the CSCI. Although appropriate door locks have been fitted to some bathroom, toilet and bedroom doors, locks still require fitting to many doors to ensure the residents privacy. The wash hand basin in the first floor sluice room was dirty. In addition, soiled incontinent pads had been put in the clinical waste bin kept in this area without them being double wrapped. Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 15 Members of care staff must therefore have transported the soiled pads from the residents rooms without first putting them in the small clinical waste bags provided for this purpose. Two dirty commode pots had been left in the shower room/toilet on the first floor of the building. The wash hand basin in this room is coming away from the wall and has been out of use for approximately two weeks. A second emergency call lead also requires installing in this room near to the shower area. The laundry room is situated on the ground floor of the home and on the day of the visit it appeared clean and well organised. Laundry assistants are employed over seven days to provide the laundry service. The area behind the washing machines needed cleaning. Hand washing facilities are provided in the laundry area, however no soap was available to the wash hand basin in the adjacent sluice room. Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30. The skill mix and numbers of staff are sufficient to meet the needs of the residents. The staff are being provided with the right level of training to make sure that they are competent to do their jobs and that the residents are safe. EVIDENCE: Duty rotas indicated that there are sufficient nursing and care staff to meet the needs of the residents. The staff are supported in their role by ancillary staff carrying out domestic, laundry and catering staff. At the present time only one member of the care staff team has completed NVQ at level 2. Seven carers have almost finished their NVQ at level 3. Four carers have recently commenced studying for a NVQ at level 2 with a further three care staff registered for the course. All the domestic staff are undertaking an NVQ cleaning support course at level 1. The activities co-ordinator is studying for a NVQ in customer care, and the office administrator is studying for a NVQ in business administration. Six members of the care staff team are studying for the intermediate certificate in nutrition and health. Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 17 Fire training is undertaken by the staff team twice yearly in June and December. Four qualified nurses have attended a course on continence management and catheter care. A pressure sore prevention course has been booked for January 2006. All members of care staff are booked on both a first aid course and food hygiene course in December 2005. In addition the manager confirmed that infection control training is to be organised in conjunction with the Thomas Danby College. Staff spoken to, confirmed that they were very happy with the level of training presently made available to them, and a number of staff who had previously been reluctant to study for a NVQ had agreed to undertake the training. In general there appears to be more commitment to staff training than on previous visits to the home. Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. The management of the home is reasonable well organised and there is a commitment to involving the staff and residents in the running of the home. The interests of the residents are safeguarded at all times. EVIDENCE: The current manager has been in post for a few weeks. She has managed the change well and there has been little disruption for residents or staff. Her application to be registered has yet to be completed by the CSCI. The manager and the new Head of Clinical Governance and Clinical Specialist Care for the Dukeries Healthcare Limited carried out an internal quality assurance audit in October 2005. The results of the audit indicated that home achieved an overall score of 51.75 , which gave it “priority” status. Although the manager was unsure Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 19 what in practical terms “priority” status actually meant, she said that she had already addressed many issues raised in the report. Prior to the new manager taking up post quality assurance questionnaires had been sent out to residents, relatives and members of the staff team. However, the previous manager had not summarised the results of the survey, or addressed the matters raised, and had simply filed the information gathered. The home now intends to carry out a new quality assurance survey and publish the results. Clear channels of communications are facilitated within the home by means of regular resident/relatives and staff meetings. Money is held in safekeeping for sixteen residents and transaction sheets are available indicating income, expenditure and a balance. All money is held in separate wallets, and the administrator is the only person who has access to the safe. The administrator and manager both sign the financial transaction sheets and a monthly reconciliation of the money held is undertaken. The home will only hold a maximum of £200 per resident in safekeeping and receipts are always obtained for purchases made by members of staff on behalf of residents. One resident deals with his own financial affairs, however it was noted that there was no key available to the lockable facility in his room and the bedroom door did not lock. The manager confirmed that she would address this matter and ensure that he could securely lock away his money, chequebook etc. At the present time the home does not hold valuables in safekeeping for any residents. The fire register was reviewed and it showed that the fire alarm and emergency lighting are tested on a weekly basis. A fire risk assessment has been completed for the building and fire drills are held at regular intervals during the year. All portable electrical appliances were tested in January 2005 and are tested on an annual basis. Comprehensive health and safety policies and procedures are in place at the home to safeguard the residents and staff team. The manager confirmed that policies and procedures are reviewed at least annually to ensure that they comply with present legislation and good practice guidelines. Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X x X 2 STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 21 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 OP7 Regulation 15 Requirement 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) Records must contain evidence that the health needs of service users are met and are reassessed when necessary. (previous timescale of 23/08/04) 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) A planned programme of refurbishment work must be forwarded to the CSCI. The provider must continue to DS0000001350.V259759.R01.S.doc Timescale for action 05/01/06 2. OP8 13(1) 05/01/06 3. OP10 12(4)(a) 05/03/06 4. 5. OP19 OP28 23(2)(b)( d) 18 05/03/06 31/12/05 Page 22 Kirkstall Court Care Home Version 5.0 work towards ensuring that 50 of the care staff are trained to NVQ level 2. 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 OP26 OP33 Good Practice Recommendations The manager should make sure that staff are aware of their responsibilities with regard to cross infection. The outcome of audits carried out as part of the quality assurance programme should be shared with all interested parties. Kirkstall Court Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 23 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 Care Home DS0000001350.V259759.R01.S.doc Version 5.0 Page 24 - 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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