Inspection on 25/05/07 for Kirkstall Lodge

This inspection was carried out on 25th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kirkstall Lodge 21/11/06

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 Key Unannounced Inspection 25th May 2007 09:30 Kirkstall Lodge DS0000053104.V341012.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.V341012.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.V341012.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 F/P 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.V341012.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 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 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 residents 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 reception area of the home. Fees range from £950.00 to £1,514.09 per week and depend on the individual care needs of each resident. Kirkstall Lodge DS0000053104.V341012.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. The inspection involved discussion with residents, staff and the newly appointed home manager. Records relating to care, staffing and environmental safety were examined there was a tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: The guide to the home must be revised to incorporate additional information about fees in line with recent changes in legislation. There must be a greater focus on risks posed to individual residents and detailed plans must be drawn up on how these risks can be minimised. The registered provider must develop ways of assessing the quality of the services provided by the home. Kirkstall Lodge DS0000053104.V341012.R01.S.doc Version 5.2 Page 6 Actions taken to address complaints made by residents, or their representatives, must be recorded. There must be better recording of the financial situation of each resident and steps must be taken to ensure that resident’s savings are safe and accessible. The home manager must apply to register with the Commission. One bedroom has an unpleasant smell. This must be addressed and steps taken to prevent reoccurrence so that the resident has a pleasant bedroom environment. 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.V341012.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.V341012.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. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Prospective residents have accessible information 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. EVIDENCE: The statement of purpose is revised to include recent changes in home management. The document contains information about the registered provider, staff in the home and how the service is run. There is also a guide for people using the service. This contains a summary of the ‘statement of purpose’ 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 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 Kirkstall Lodge DS0000053104.V341012.R01.S.doc Version 5.2 Page 9 where a person’s care is funded, in whole or in part, by someone other than the person. 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 resident was recently admitted to the home. The resident 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 the persons 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. A placement review is planned to assess how well the person is settling in to the home. Staff said that the placement is going well. Kirkstall Lodge DS0000053104.V341012.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. Written plans must be revised to include greater detail about the type of staff support that each person requires and there must be thorough investigation of known risks and plans made for what staff should do to keep residents safe. Residents are given support and opportunities to make decisions about their lives where possible. EVIDENCE: Each resident has two files of written information about their care needs. The care records for two residents provide evidence that placing authorities have reviewed the needs of individual residents living in the home. The minutes of these reviews are available. Each resident has a comprehensive set of assessment documents providing detailed information about care needs and planned care and support. These documents include: Kirkstall Lodge DS0000053104.V341012.R01.S.doc Version 5.2 Page 11 • • • • • • • • • • • • • • • • • • 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) Residents who are able have, in some cases, also added their comments to each element of the care plan. This is good practice. A planned six monthly review of one set of care and support plans has not yet taken place and is now overdue. Additionally, an essential risk assessment in regards to problems with swallowing and choking is not available. This risk was highlighted in a report by a health professional and was the subject of a requirement in the previous inspection report. A risk assessment about the risk of a resident choking during her sleep was subsequently supplied to the Commission on 1st June 2007. This document does not identify action to be taken by staff if they notice that the resident is coughing whilst eating (a health professional report on the subject says that staff should contact the health professional immediately if they notice any increase as this could lead to choking). (See requirement 3) The list of priorities and current goals reflects the goals identified in recent placing authority care reviews. In some cases the support that is actually provided is not reflected in sufficient detail in written plans. For example, one resident is of African-Caribbean heritage but a written plan to identify how his cultural needs are to be met has no information at all. A member of staff, of the same culture as the resident, spoke confidently about how these cultural needs are addressed and the resident seems pleased with his new home, especially some of the culturally appropriate meals that staff prepare. (See requirement 2) Kirkstall Lodge DS0000053104.V341012.R01.S.doc Version 5.2 Page 12 One resident requires support to manage her continence needs, although a care plan gives little practical information of how this support is to be provided. Discussion with staff on duty indicates a lack of consistency in this area and a written plan will identify the consistent approach required. (See requirement 2) 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. A risk audit tool is now in place, as recommended in the previous inspection report. This lists areas of risk to be considered for each person. If a particular activity or situation presents a hazard to a resident a more detailed risk assessment is developed to include action that staff should take to reduce the danger. Residents have a learning disability and need support with communication and decision-making. There is progress in training staff to recognise and use signed communication and to develop a range of pictures and photographs to assist in communicating information about choices and plans. Each resident has a key-worker from within the team who meets with them regularly, makes appointments, updates records and plans and monitors progress in achieving specific goals. There are reports of key-working activity available and these include records of discussion and meetings with residents. Relatives and advocates are also involved in some cases and multidisciplinary meetings in the best interest of individual residents are called when major decisions are to be made, for example health treatment under any form of sedation. There are ‘house’ meetings where residents 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. Residents require 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 people to be better recorded. These requirements are now met. Each resident and key worker now has written information about state benefits collected on the resident’s behalf by the registered provider and records relating to individual expenditure are well kept. Kirkstall Lodge DS0000053104.V341012.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 adequate This judgement has been made using available evidence including a visit to this service. Residents are supported to maintain and develop a fulfilling quality of life. There are opportunities for personal development and leisure and to maintain and develop friendships and relationships. There is a healthy diet that meets the cultural and nutritional needs of each resident. More must be done to promote the rights of residents and ensure their privacy. EVIDENCE: Residents 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 group or individual holidays. Residents maintain their friendships and relationships whilst living in the home, with visits, telephone calls and letters. Kirkstall Lodge DS0000053104.V341012.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. One resident is supported to attend a mosque on a regular basis and there is good contact with his family. A range of culturally appropriate meals are prepared and served. The daily routines in the home are structured so that residents are woken in adequate time to prepare for their days activities. Residents were observed to move freely around the building, choosing whether to sit in a communal area or in their own bedrooms. Residents are also encouraged to get involved with cooking and laundry tasks. A resident made a complaint about a member of staff entering his bedroom whilst he was out of the house without his permission. The member of staff removed some items that she wished to be returned to his family, as she did not think the items were appropriate gifts. The resident was angry and upset. This is unacceptable. Should a situation arise like this again it must be handled in a way that respects the feelings and privacy of the resident. The member of staff has since resigned and no longer works in the home. (See requirement 4) Residents are provided with a key to their bedroom door locks if they are able and wish to use it. The front door has recently been fitted with a keypad type lock and residents, who cannot remember the code, are no longer able to open the front door. Staff said that the lock has been fitted to prevent one resident from leaving the home without staff knowledge and all residents need staff support to stay safe whilst out in the community. The need for such levels of security should be reviewed regularly so that residents are not denied their right to open their own front door themselves unnecessarily. (See recommendation 1) 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 and culturally appropriate meal choices. Individual likes and dislikes are also recorded. One resident requires support with eating meals and with ensuring that food is cut up properly. Before the previous inspection a relative queried the arrangements for paying for food when a resident stays away from the home with a relative for a period of time. These arrangements should be clarified and appropriate steps taken to reimburse relatives when appropriate. (See recommendation 2) Kirkstall Lodge DS0000053104.V341012.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 good This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and require and their physical and emotional needs are addressed. The support that residents receive with taking their medication is safer and simpler. 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 three male residents and two female residents. There are both male and female staff available to provide personal care, but same sex assistance with personal care cannot always be guaranteed. 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. Kirkstall Lodge DS0000053104.V341012.R01.S.doc Version 5.2 Page 16 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. 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 resident and each person has specific health goals, for example, exercise and healthy eating plans to aid weight reduction are going well for one resident, improving her mobility and ability to move around independently. Lambeth SLAM NHS Trust Health Action Plans are completed for resident but have yet to be shared with associated health professionals. It is recommended that this be done on an individual basis to ensure that residents get professional advice appropriate to their individual healthcare needs. (See recommendation 4) Medical, health and progress notes show evidence of effective health monitoring. None of the current residents are managing their own medication and all need support from staff. All staff administering medicines receive training. Certificates are available in staff training records. Medication is stored in a locked cabinet in the staff office. A measured dose system is in place and new stocks are collected from the supplying pharmacist along with pre-printed medication administration records. Records examined have no gaps and are completed accurately. The use of external products (such as creams) is recorded. There is a sample list of staff signatures so that the person who administered a medication and signed the record can be identified easily. There is good information about the medication in use and the side effects they might have. Staff spoke about how they observe a persons demeanour to assess levels of comfort or pain in some cases. This level of observation is necessary as some residents are not able to tell staff that they are in pain. There are no ‘over the counter’ remedies, such as painkillers, available, unless they are prescribed. Kirkstall Lodge DS0000053104.V341012.R01.S.doc Version 5.2 Page 17 The GP can advise on what over the counter remedies each resident can safely take and a small amount should be available, in case someone develops an earache, headache or toothache during the night. (See recommendation 4) During the last inspection a requirement was made in regard to failing to keep accurate records when supplies were obtained from an alternative pharmacist who did not supply pre-printed medication administration records. Staff had administered medication without keeping an accurate record. This has not occurred again and the requirement to maintain adequate records is therefore met. There is also evidence that appropriate action is taken when staff make mistakes with medication. A member of staff administered a medication that was no longer prescribed. Medical advice was sought immediately and the member of staff was disciplined and re-trained appropriately. All residents are taking their prescribed medicines regularly and no prescribed medication is out of stock at the time of this inspection. Kirkstall Lodge DS0000053104.V341012.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. Staff are getting better at recording when a resident makes a complaint, but it is not clear what action is taken by the registered provider in response. Residents cannot be confident that they are listened to. EVIDENCE: Given that the residents are not able to make formal written complaints without assistance, the previous inspection report recommends that staff assist residents to record any complaints or concerns they may have. This recommendation has been implemented and three complaints are recorded. A resident complained about a member of staff entering his bedroom and removing items. A resident complained about the condition of his bedroom carpet. A resident complained about the behaviour of another resident. The actions taken to investigate the complaints, the outcome of the investigations and what feedback is given to the complainant is not recorded. (See requirement 5) There have been many complaints from a neighbour about noise levels in the home. Further meetings are scheduled between the registered provider and the neighbours to monitor progress in addressing this ongoing issue. Kirkstall Lodge DS0000053104.V341012.R01.S.doc Version 5.2 Page 19 Staff are trained in adult protection and abuse awareness and procedures are in place for responding to suspicion or evidence of abuse or neglect (including whistle-blowing) to ensure the safety and protection of residents. Procedures are in place for staff to be suspended pending investigation of any allegation or suspicion of abuse and for notifying appropriate authorities. Although there is better information about each person’s income and personal expenditure there are a variety of historical financial situations. For example, a bank card is held in safe keeping but the resident is not able to remember the pin number, so one member staff uses it on her behalf. One resident cannot access savings as an account is frozen. These individual financial matters are not documented and staff related some of the issues anecdotally. It is recommended that there be a review of the financial circumstances of each resident to ensure that their financial matters are up to date, and that they are receiving adequate and appropriate support and advise to protect them from financial abuse. (See requirement 6) Kirkstall Lodge DS0000053104.V341012.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 & 30. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is small but comfortable and it is not distinguishable as a care home. Steps are taken to ensure the environment is safe and the home is reasonable well furnished and decorated. An unpleasant odour in one room is unacceptable. 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 small communal lounge with a dining area, a small kitchen and patio access to a small rear garden. There is also a small office within the communal lounge and another small office in a garden outhouse. Kirkstall Lodge DS0000053104.V341012.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, some residents need support from staff to personalise their bedrooms and more could be done to assist some of the residents whose rooms are a little bare. (See recommendation 5) Two of the residents assisted with a tour of the premises and both are happy with their bedrooms. One resident was keen to pint out that one of the toilets is not flushing properly and staff advise that the matter is reported and they are awaiting a repair. All bedroom door locks are of a type that can be over-ridden by staff in an emergency. The rear garden is reasonably level and there is a handrail fitted. This is of use to one of the residents who has difficulties with mobility. There is a sturdy garden chair and a new covered arbour for one resident who enjoys a cigarette in the garden. One ground floor bedroom has an unpleasant smell of urine. The occupying resident has continence needs. This is unacceptable. (See requirement 7) 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.V341012.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. Staff are well vetted before they are allowed to work in the home with vulnerable residents. Staff training is appropriate and there is ongoing improvement in ensuring that staff are adequately qualified and supervised. EVIDENCE: There is an ongoing staff-training programme. The new manager has developed a training needs analysis for 2007. This analysis identifies training and refresher courses needed by individual staff this year. Planned training includes: • First Aid • Health and Safety • Medication • Challenging behaviour • Adult protection • Food hygiene • Fire prevention • Supervision Kirkstall Lodge DS0000053104.V341012.R01.S.doc Version 5.2 Page 23 • • • Moving and handling Care planning Risk assessment Of the nine staff: • One has an NVQ level 2 in Care • Three are currently undertaking an NVQ 2 • One is currently undertaking an NVQ 3 • Five are due to be booked onto an NVQ course at level 2 or 3 An NVQ is a nationally recognised vocational qualification designed to prepare staff to work in care settings. The minimum standard expected is that all staff achieve this qualification (or a similar or equivalent qualification). Although there is progress in this service and plans are in place to achieve this, the minimum standard is not yet achieved. (See requirement 8) Staff were observed to interact well with residents and discussion with individual staff members indicates an understanding of the needs of the residents. Recruitment records examined during this inspection indicate that staff are adequately vetted before they are allowed to work in the service. Records obtained include proof of identity and address, an application form, interview record, copies of training certificates already obtained, a self-declaration of health and criminal conviction and references. Each member of staff has an enhanced criminal record bureau check in place. There is also evidence of improved training for staff when they first join the team, as required in the previous inspection report. Induction training records are in place for all new staff and are in accordance with ‘Skills for Care’ guidelines. Individual staff files show that staff are now meeting with their line managers on a regular basis for one to one supervision meetings, as required in the previous inspection report. Kirkstall Lodge DS0000053104.V341012.R01.S.doc Version 5.2 Page 24 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. Home management has changed frequently in the last year and this is unsettling for staff and residents. The registered provider must do more to assess the quality of the services provided. Health and safety checks are in place but must be reviewed in regards to fire safety. EVIDENCE: The manager appointed before the last inspection has since resigned and did not register with the Commission. A new home manager was appointed in March 2007 but is not yet registered with the Commission. (See requirement 9) Kirkstall Lodge DS0000053104.V341012.R01.S.doc Version 5.2 Page 25 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 Commission. Quality monitoring systems are not fully developed and do not include stakeholder audits. (See requirement 10) 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 by staff each week, and the fire fighting and detection equipment is also professionally tested on a regular basis. Staff do not know whether the new keypad security system on the front door affects the plan for emergency fire evacuation in any way (residents are unable to open the door). This must be investigated and steps taken to ensure effective and safe evacuation from the building if necessary. (See requirement 11) 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 (now due for re-testing) • The mains electrical system was tested on 03/11/03 • Small electrical appliances were tested ion 01/03/07 • 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 hygiene monitoring. Kirkstall Lodge DS0000053104.V341012.R01.S.doc Version 5.2 Page 26 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 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 1 X 1 X X 2 X Kirkstall Lodge DS0000053104.V341012.R01.S.doc Version 5.2 Page 27 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 timescale of 31/03/07 for meeting this previous requirement is unmet. 2. YA6 15 12 The registered person must 31/08/07 ensure that each resident has a written plan of care that provides staff with detailed information about how all identified care needs will be met. The registered person must 27/07/07 review and assess the risks posed to each individual service user. Although there is progress the timescale of 31/12/07 for action to be taken to meet this previous requirement is not met. 4. YA16 12 The registered person must ensure that staff do not enter residents bedrooms without permission. Staff must not remove personal possessions DS0000053104.V341012.R01.S.doc Timescale for action 28/09/07 3. YA9 13 27/07/07 Kirkstall Lodge Version 5.2 Page 28 without taking into account the wishes and feelings of residents and the need to maintain good and professional relationships with them. 5. YA22 22 17 The registered person must establish a complaints procedure that is appropriate to the needs of the people using the service. A record must be kept of all complaints made by service users or their representatives or relatives or by persons working at the home about the operation of the home, and the action taken by the registered person in respect of such complaint. The registered person must review the individual support that each person receives with personal banking and financial matters and must make sure that they are receiving appropriate support and are protected from financial abuse. The nature of any financial support must be recorded. The registered person must ensure that all areas of the home are free from offensive odours. The registered person must ensure that steps are taken to ensure that all staff attain a vocational qualification in providing care. The registered person must submit an application for the post of registered manager to the CSCI. The registered person must ensure that an annual development plan is formulated, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. 27/07/07 6. YA23 16 17 31/08/07 7. 8. YA24 YA32 16 18 27/07/07 28/09/07 9. YA37 8 27/07/07 10. YA39 24 28/09/07 Kirkstall Lodge DS0000053104.V341012.R01.S.doc Version 5.2 Page 29 The previous timescales of 30/10/06 and 31/13/07 for action to be taken to meet this previous requirement are not met. 11. YA42 12 The registered person must investigate the impact of the front door security on safe fire evacuation and take any necessary steps to ensure safety. 27/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. Refer to Standard YA16 YA17 Good Practice Recommendations The registered person should regularly review the need for keypad access to the building and the community to ensure that residents are offered the option of using. 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 persons GP and/or other appropriate health advisor. The registered person should seek advice on obtaining a small stock of home remedy medicines so that residents have access to pain relief for minor ailments out of hours (for example during the night or at the weekend when a GP or dentist might not be so readily available). The registered persons should assist residents to personalise their bedrooms if they wish. 3. 4. YA19 YA20 5. YA26 Kirkstall Lodge DS0000053104.V341012.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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