Inspection on 21/11/06 for Kirkstall Lodge

This inspection was carried out on 21st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kirkstall Lodge 25/05/07

Kirkstall Lodge 25/07/06

Kirkstall Lodge 06/10/05

Kirkstall Lodge 23/04/05

Kirkstall Lodge 07/02/05

Kirkstall Lodge 08/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Kirkstall Lodge 56 Kirkstall Road Streatham London SW2 4HF Lead Inspector Sonia McKay Unannounced Inspection 21st November 2006 09:30 Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 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 Lodge DS0000053104.V321214.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 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. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirkstall Lodge Address 56 Kirkstall Road Streatham London SW2 4HF 0208 678 8296 0208 678 8296 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) Kirkstall Lodge Limited Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2006 Brief Description of the Service: Kirkstall Lodge is a care home for six adults with a learning disability. The semi-detached house is located in a residential street in Streatham, South West London. It is close to public transport routes, shops and leisure facilities. The home is unsuitable for people with restricted mobility as front access is via a number of steps. There is a small rear garden with an outbuilding that is used as an office. The home is owned and managed by Beacon Care, a private care provider with many other homes in London and the South East of England. Support is provided by a staff team of support workers and a home manager. The home has use of a vehicle and employs a support worker/driver to assist with the numerous journeys back and forth to the various day services/activities attended. Prospective service users are given a copy of the Service Users guide that gives information about the home and the services provided. A copy of the most recent CSCI inspection report is available in the home on request. Fees range from £950.00 to £1,514.09 per week and depend on the individual care needs of each service user. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out in seven hours over one day, and is the second key inspection carried out in 2006. The inspection involved discussion with the newly appointed home manager, examining the care arrangements in place for one service user, looking at records, observation of activities and a partial tour of the premises. What the service does well: What has improved since the last inspection? A new home manager has been appointed, giving necessary leadership to the service and a deputy home manager has been appointed to assist with the management of the service. Records are better organised so that the staff can locate information about the current needs and goals of each service user. The garden area is more accessible to a service user with a mobility need, and there is now a level path, a handrail and suitable seating. A service user has moved back to the bedroom of his personal preference and contracts of occupancy now state which bedroom will be occupied under the agreement. Service users who are able and who wish to now have a key to their bedroom doors and to the front door of the home. Staff are better trained in the safe administration of medication to service users. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about moving to the home. Individual aspirations and needs are assessed during a resettlement process that provides an opportunity to visit and to’ test drive’ the home before making a decision to move in. Each service user has an individual written contract detailing their terms and conditions of occupancy. EVIDENCE: The statement of purpose is revised to include recent changes in home management. The document contains all of the required information about the services provided and the fees charged. There is also a guide for people using the service. This contains a summary of the purpose of the home and a description of the services provided. The guide is user friendly and contains many colour pictures, making it more accessible to people who would find a text only document difficult. Regulations about the service user’s guide have been amended to require greater detail to be included about the standard package of services provided Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 9 in the care home, the terms and conditions which apply to key services, fee levels and payment arrangements. The guide is also required to state whether the terms and conditions (including fees) would be different in circumstances where a service user’s care is funded, in whole or in part, by someone other than the service user. Any notice of an increase of fees is to be accompanied by a statement of the reasons for such an increase. (See requirement 1) A new service user was recently admitted to the home. The service user had an opportunity to visit the service before making a decision to move in and the registered provider obtained a detailed community care assessment of needs from the placing authority before completing their own assessment, records of which are held on file. An initial care plan is in place based on the care management assessment and the homes own needs assessment. The initial care plan and care arrangements were recently reviewed by the placing authority and the suitability of the placement is now confirmed. Contracts of occupancy have been revised to include details of the bedroom to be occupied under the agreement, as required in the previous inspection report. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users assessed and changing needs and personal goals are reflected in their individual plans. Service users need and receive assistance to make decisions about their lives, although more must be done to ensure informed choice and appropriate assistance with managing personal finances. Although some risks are adequately assessed, there is a need for a thorough assessment of any specific risks posed to each person to ensure that staff have sufficient information about action to be taken to reduce risks and to enable service users to develop lifestyles that are as independent as possible. EVIDENCE: Each service user has two files of written information about their care needs. The care records for three service users were examined. Records examined suggest that placing authorities have reviewed the needs of individual service users living in the home. The minutes of these reviews are available. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 11 Each service user has a comprehensive set of assessment documents providing detailed information about care needs and planned care and support. These documents include: • Contact information for family members and professional involved • A pen portrait of each person and a photograph • A brief life history • Health issues • Psychological support and mental health needs • Support required to manage any emotional needs • Communication skills • Guidelines for personal care • Self care skills • Relationships and sexual needs • Community presence and participation • Recreation and relaxation • Cultural and spiritual needs • Employment and education • Finances • Strengths and needs • Likes and dislikes • List of priorities (current goals) Service users who are able have, in some cases, also added their comments to each element of the care plan. This is good practice. The home manager and staff have reviewed the files and archived out of date information, as recommended in the previous inspection report. The information available is now clear and there is a list of priorities and current goals reflecting the goals identified in recent placing authority care reviews, as required in the previous inspection report. There is a form for staff to sign to confirm that they have read and understood care information contained in the files. This is also good practice. It is not clear whether all required risk assessments are in place as a risk audit tool is not available. For example, one service user has PICA, excess salivation and difficulty swallowing, there is no specific risk assessment relating to the risks that this presents although a therapists report states that the frequency of coughing during meals should be monitored and any increase in coughing should trigger prompt referral back to the specialist team for adults with a learning disability. (See requirement 2 & recommendation 1) Service users have varying degrees of learning disability and communication ability. Evidence gathered through observation indicates that service users are encouraged and supported to make day-to-day decisions to the best of their Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 12 individual ability, and there is progress in training staff to recognise and use signed communication. There is also progress in developing a wider range of visual planners, which use pictures and photographs as well as words making information more accessible. Each service user has a key-worker from within the team who has responsibility to assist them to understand documents, to make choices, develop plans and goals and to keep records. There are reports of key-working activity available and these include records of discussion and meetings with service users. Relatives and advocates are also involved in some cases and multidisciplinary meetings in the best interest of individual service users are called when major decisions are to be made, for example health treatment under any form of sedation. There are ‘house’ meetings where service users can discuss issues as a group and make decisions with staff. These meetings are held regularly and are used to decide on issues such as group outings. Service users require varying levels of support to manage their finances. In some cases they need full support and the registered provider is the state benefit appointee. A requirement was made during the two previous inspection visits for the nature of financial support to be better documented and for financial transactions made on behalf of individual service users to be better recorded. This requirement is partly met. Whilst records of cash balances are well recorded and receipts are retained for items purchased, the full financial picture for each service user is not clear. There is no record of benefits collected, charges to service users and bank account balances or of the nature of support required for each individual to manage their finances. The home manager and staff cannot therefore have a clear picture of individual budgets to enable them to support service users to effectively manage their personal finances in terms of clothing and sundry purchases. For example, one service user smokes cigarettes although it is not clear whether she able to do so by using her savings. (See requirement 3) During the previous inspection it was noted at one service user had moved bedrooms and no longer had an en-suite bathroom. The bedroom was then used as a staff ‘sleeping in’ room. It was not clear how or why this decision was made or whether the service user was involved in making it. As a result of a requirement made in the previous inspection report the service user was consulted about his personal preference and the decision was made to assist him to move him back to his original bedroom. The service user confirmed he is now happy with his bedroom. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are supported to maintain and develop a fulfilling quality of life, and there are opportunities for personal development, appropriate activities and leisure, access to the local and wider community and friendships and family relationships. There is a healthy diet that meets the cultural and nutritional needs of each service user. EVIDENCE: Service users are involved in a variety of daytime activities; these include attending day centres, college courses and one-to-one activities with staff. There is a house vehicle and a member of the support team is employed as a support worker/driver. There are outings to places of interest and service users have been on holiday in groups this year. Service user can maintain their friendships and relationships whilst living in the home, with visits, telephone calls and letters. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 14 There is a television and music centre in the communal lounge and arts and crafts materials are available. The cultural and spiritual needs of individual service users are recorded and steps are taken to meet these needs. For example one service user regularly attends the mosque with family members and culturally appropriate meals are prepared and served for one service user who is Italian. Staff were observed to interact well with service user and to readily engage in conversation. A placing authority review recommended that staff communicate more using signed communication for adults with a learning disability. A speech and language therapist has being working with the team to increase their skill in this essential area. Further staff training in signed communication is recommended. (See recommendation 2) Meals are served in the dining area of the communal lounge. Records indicate that a range of meals are served in accordance with individual needs, such as wheat free, dairy free, meals suitable for someone with diabetes and culturally appropriate meal choices. Individual likes and dislikes are also recorded. One service user requires support with eating meals and with ensuring that food is cut up properly. A relative has queried the arrangements for paying for food when a service user stays with a relative for a period of time. These arrangements should be clarified and appropriate steps taken to reimburse relatives when appropriate. (See recommendation 3) Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users receive personal support in the way they prefer and require and health care needs are addressed promptly. There is progress in developing pro-active healthcare plans. Medication is generally handled well although administration instructions are not in place and in some cases records have not been kept appropriately. EVIDENCE: Service users require varying levels of support with maintaining their personal hygiene from full support to verbal prompting. Personal support is provided in private, either in bedrooms or in bathrooms and each service user has a written personal care guideline detailing the nature of support required. There are currently two male service users and three female service users. There are both male and female staff available to provide personal care, but same sex personal care cannot always be guaranteed. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 16 There is a designated key worker system in place and on occasions when additional staff are required they are supplied via a bank system from another home run by the registered provider. There is evidence that appropriate advice is taken in regard to specialist support from physiotherapists, occupational therapists and speech therapists and necessary adaptations and equipment are in place. There is evidence in records that the healthcare needs are well met and healthcare records are reorganised so that there is a clear record of healthcare needs and the outcome of appointments, as recommended in the previous inspection report. Records of health appointments show that service users have regular input from the GP, dentist and other health professionals. A health needs assessment is completed for each service user, and each service user has specific health goals, for example, exercise and healthy eating plans in place to aid weight reduction. Lambeth SLAM NHS Trust Health Action Plans are completed for each service user. Most identified health needs have associated care plans. The home manager is currently developing the health action plans and intends to seek advise from a GP about pro-active healthcare needs. (See recommendation 4) Medical, health and progress notes show evidence of effective health monitoring. As part of the consultation during the July 2006 inspection a GP from the local group practice confirmed that: • Staff from the home communicate clearly and work in partnership with the group practice • Senior staff are available to confer with • Consultations are held in private • Staff demonstrate a clear understanding of the care needs of service users • Specialist health advice is incorporated into plans • Medication is managed appropriately • Managers and staff make appropriate decisions when they can no longer manage the care needs of service users • No complaints have been received about the home • Satisfaction with the overall care provided to service user within the home All service users are taking their prescribed medicines regularly and no prescribed medication is out of stock at the time of this inspection. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 17 The supplying pharmacist conducts regular audits and medical device alerts have been printed off and retained. A district nurse visits one service user each day to administer insulin. Each visit is recorded, and MAR (Medication Administration Records) are signed to record the injection has been given. The date that the insulin is opened is recorded. There is a written risk assessment and guideline for what to do if the service user goes into a diabetic coma and there is adequate information available to enable staff to prepare suitable meals. The variable dose of insulin administered by the District Nurse is now recorded, as recommended in the previous inspection report. The use of external products (such as creams) is recorded. Service users are given their medication when they are away from the home, for example, on holiday or when they out for the day. Some prescribed items were not collected from the supplying pharmacist recently, and the GP arranged for emergency supplies to be collected from an alternative pharmacy as an interim measure. The prescribed items were supplied without clear directions on the printed labels and no MAR charts were filled in for a 24-hour period, as the pre-printed MAR charts are usually supplied by the regular pharmacist along with medication stock and were not supplied along with the emergency supply received from the alternative pharmacy. Staff confirmed that all prescribed medications were administered using instructions on previous MAR sheets. This is not safe. (See requirements 4 & 5) Quantities of PRN medicines have been added to MAR charts to enable effective stock checking, as required in the previous inspection report. All staff administering medicines receive training. Certificates are available in staff training records. The pharmacist provides some training and staff also attend a three hour workshop. Further training is booked via a community college course. The home manager completes a competence assessment at the end of the training, as required in the previous inspection report. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is a complaints procedure in place, although care must be taken to ensure that procedures for recording complaints are suitable to the needs of the service users. Adult protection procedures are in place and staff are trained to recognise abuse and to take appropriate action. The registered provider must take advise about referring a dismissed member of staff to the POVA list. EVIDENCE: There is a complaints procedure in place. The record of complaints shows that there have been no complaints made in the last 12 months by service users. There are regular opportunities for service users to discuss issues during regular key work and house meetings. Given that the service users are not able to make formal written complaints it is essential that a record be kept of any complaint made verbally, and that such complaints/concerns are listened to acted upon accordingly. (See recommendation 5) There have been many complaints from a neighbour about noise levels in the home. A meeting is scheduled for these issues to be discussed with the neighbour. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 19 Procedures are in place for responding to suspicion or evidence of abuse or neglect (including whistle-blowing) to ensure the safety and protection of service users. The home manager is aware of the need to ensure that staff, awaiting full enhanced criminal record checks, are subject to satisfactory POVA first clearance before working in the home and the need for staff with only POVA first clearance to be supervised whilst working. The regional manager took appropriate action as a result of a recent allegation of abuse against a member of staff, notifying appropriate authorities and suspending a member of staff. However, it is not clear whether the member of staff, who refused to take part in a disciplinary investigation and was subsequently dismissed, has since been referred to the POVA list of people who must not work with vulnerable adults. (See requirement 6) Staff have not now all been trained in adult protection and abuse awareness, as required in the previous inspection report. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 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. Quality in this outcome area is adequate. This judgement has been made using available evidence include and clean and there is improvement in the accessibility of the communal garden area for one service user with mobility needs. More must be done to ensure that each service user has appropriate furniture and fittings in their bedrooms. EVIDENCE: The small home is clean, comfortably furnished and well decorated. All bedrooms are single occupancy. There are two ground floor bedrooms, one with en-suite bathroom facilities. There is also a ground floor wet shower room with a separate toilet. The ground floor has a communal lounge with a dining area, a small kitchen and patio access to a small rear garden. There is also a small office area within the communal area and another small office is in the garden. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 21 The first floor has four bedrooms, one of which has en-suite bathroom facilities. There is a bathroom with a toilet and a small laundry room. One bedroom is currently used for staff that are sleeping-in at night. All bedrooms are well decorated and furnished attractively, although not all contained the fixtures and fittings listed in the national minimum standard, for example, lockable areas and a second comfortable chair. (See requirement 6) During the previous inspection it was noted that one bedroom door lock was missing. This has been replaced, as required. One service user has also been provided with a key to his bedroom door and the front door. All locks are of a type that can be over-ridden by staff in an emergency. The rear garden was not accessible to one of the service users who has a mobility need. The garden path has been levelled and a handrail fitted and a wooden garden bench has replaced the plastic garden chairs. This provides improved accessibility and safety. One service user, who was recently admitted to the home, likes to smokes cigarettes in the garden, as there is only one communal lounge and that is maintained as a smoke free environment. A garden shelter of some description is recommended. (See recommendation 6) One service user refuses to sleep in a bed and prefers to sleep in a reclining chair instead. This is not ideal and may have detrimental affects on her health. Advice was sought from a qualified occupational therapist, as required in the previous inspection report. The alternative arrangements recommended have not been successful and strategies to resolve this situation are still ongoing. Bathrooms and toilets are fitted with appropriate privacy locks and hot water is regulated to within safe temperature limits and tested regularly. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home manager demonstrates a thorough approach to staff recruitment, but the induction training is out of date with current guidance. There is progress with training the staff team although a thorough analysis of need is required and a suitable programme of training developed to ensure that staff are trained in the specific needs of the current service users. EVIDENCE: There are currently seven members of staff working in the home, the staff complement comprises of: • One deputy manager (a recent appointment) • One senior support worker • Two night support workers • Three day time support workers There are currently two full time vacancies that are covered by regular staff doing overtime, bank staff or agency staff. There are three members of staff on duty during the day and two staff on duty at night, although one is on ‘sleep-in’ duty. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 23 A recent recruitment drive was unsuccessful and the home manager is currently working with a recruitment agency to employ two members of staff who are also drivers. Two members of staff have attained an NVQ level 2. Four members of staff are currently undertaking this qualification. The deputy home manager is currently undertaking an NVQ level 3. The following training took place prior to the previous inspection in July 2006: • Health and safety • Food hygiene • First aid • Fire safety (only 2 staff have recent training however) • Infection control • LADF Autism • Assessment and Intervention: Mental health and learning disability • Medication competence • Person centred planning • POVA • Manual handling Not all staff had attended each training session and some required refresher courses. There is a need to ensure that all staff receive specific training in meeting the needs of the current service users. Training should include: • Communicating with adults with a learning disability • Signed communication • Diabetes • Capacity to consent • Risk assessment (See recommendation 7) The home manager is currently looking at staff training needs to develop a training plan for 2007. Induction training is in place but is not in accordance with ‘Skills for Care’ guidelines. (See requirements 8 & 9) Individual files containing records obtained and checks made during staff recruitment. These records include proof of identity and address, an application form, interview record, copies of qualifications, self-declaration of health and criminal records and references. Each member of staff has an enhanced criminal record bureau check in place. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 24 Staff records indicate that staff, including the home manager, have not been supervised with the required frequency. (See requirement 10) Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A manager is appointed and has suitable qualifications and experience to enable her to run the home, she has yet to undertake a fit persons interview with the Commission. Quality assurance systems are not adequately developed yet. Systems and checks are in place to ensure environmental health and safety. EVIDENCE: The home manager was appointed in August 2006, but is not yet registered with the Commission. (See requirement 11) Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 26 The manager has an NVQ level 3 & 4, the RMA (Registered Managers Award) and an NVQ assessor qualification and has experience of managing residential services for adults with a learning disability. A representative of the registered provider conducts monthly inspection visits to the service, in accordance with regulation. Copies of the reports of these visits are available in the home and have been supplied to the CSCI. Quality monitoring systems are not fully developed and do not include stakeholder audits. (See requirement 12) Fire evacuation procedures and a building floor plan are displayed. Fire evacuation drills are held regularly and the outcome of the drill recorded. Fire detection equipment is tested each week, and the fire fighting and detection equipment is also professionally tested on a regular basis. Records are kept of fridge and freezer temperatures and hot water temperatures are tested and recorded. Records show that temperatures are maintained to within safe limits. Building and equipment safety certificates seen show that: • The gas appliances were tested on 09/05/06 • The mains electrical system was tested on 03/11/03 • Small electrical appliances were tested in 12/04/06 • Legionella tests were conducted on 04/10/06 A food hygiene inspection as carried out by the local authority on 29/03/06. The report of this inspection comments that the food preparation and kitchen environment are satisfactory and there is good monitoring. Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 28 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 YA1 Regulation 5 Requirement The registered person must revise the service users guide in accordance with recent changes in legislation. The registered person must review and assess the risks posed to each individual service user. The timescale of 15/09/06 for action to be taken to meet this previous requirement is not met. Timescale for action 31/03/07 2. YA9 13 31/12/06 3. YA7 20 4. YA20 13(2) 5. YA20 19 13(2) The registered person must 31/03/07 ensure that the support service users receive to help with the management of their finances (including budgeting) is transparent and that information about individual bank accounts held by/or on behalf of service users are retained at the home. The registered person must 31/12/06 ensure that there are detailed instructions in place for the administration of all prescribed medications. The registered person must 31/12/06 ensure that a record is kept of all medications administered to service users. DS0000053104.V321214.R01.S.doc Version 5.2 Page 29 Kirkstall Lodge 6. YA23 19 7. YA26 23 8. YA35 18 9. YA35 18 10. YA36 18(2) 11. YA37 8 12. YA39 24 The registered person must seek advise as to whether a member of staff who was dismissed for failing to attend a disciplinary investigation, as a result of an allegation of physical abuse, should be referred to the POVA list. The registered person must ensure that bedrooms contain all items listed in national minimum standard 26.2. Where a service user expressly refuses a particular item a record of this decision should be kept in the persons individual plan. The registered person must ensure that all staff receive a structured induction to the home and induction training in accordance with Sector Skills Council workforce training targets. The timescale of 31/08/06 for action to be taken to meet this previous requirement is not met. The registered person must conduct a staff training needs analysis and develop a training and development plan. This analysis and plan must be supplied to the CSCI by The registered person must ensure that staff are given appropriate levels of supervision. The timescale of 31/08/06 for action to be taken to meet this previous requirement is not met. The registered person must submit an application for the post of registered manager to the CSCI. The timescale of 31/10/06 for action to be taken to meet this previous requirement is not met. The registered person must ensure that an annual development plan is formulated, DS0000053104.V321214.R01.S.doc 31/12/06 31/03/07 31/03/07 31/03/07 31/12/06 31/12/06 31/03/07 Kirkstall Lodge Version 5.2 Page 30 based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. The previous timescales of 30/11/05 and 31/10/06 for action to be taken to meet this previous requirement are not met. 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. Refer to Standard YA9 Good Practice Recommendations The registered person should develop a risk audit tool that enables staff to methodically assess risks posed to service users and tracks current risk assessments and review dates. The registered person should train staff in effective and signed communication specifically for adults with a learning disability and communication needs. The registered person should clarify the financial arrangements for the cost of food consumed by service users when away from the home, at either a day service or when staying with relatives or friends. The registered person should ensure that individual health action plans are discussed and agreed with each service users GP. The registered person should ensure that verbal complaints made by service user are listened to, recorded and acted upon. The registered person should provide a sheltered area in the garden for service users who wish to smoke cigarettes. The registered person should ensure that staff are trained in meeting the specific needs of the current service users. Training should include: • Communicating with adults with a learning disability • Signed communication • Diabetes • Capacity to consent • Risk assessment 2. 3. YA11 YA32 YA17 4. 5. 6. 7. YA19 YA22 YA28 YA32 Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Kirkstall Lodge DS0000053104.V321214.R01.S.doc Version 5.2 Page 32 - 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!