Inspection on 17/01/06 for Kirkwood Care Home

This inspection was carried out on 17th January 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kirkwood Care Home 09/08/06

Kirkwood Care Home 22/08/05

Kirkwood Care Home 02/03/05

Kirkwood Care Home 02/09/04

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

CARE HOMES FOR OLDER PEOPLE Kirkwood Care Home 35 Moorfield Road Ben Rhydding Ilkley West Yorkshire LS29 8BL Lead Inspector Sue Dunn Unannounced Inspection 17th January 2006 10:30 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 Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 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. Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kirkwood Care Home Address 35 Moorfield Road Ben Rhydding Ilkley West Yorkshire LS29 8BL 01943 600653 01943 604144 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) The Franklyn Group Ltd Miss Sarah Joanne Brown Care Home 20 Category(ies) of Physical disability over 65 years of age (20) registration, with number of places Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2005 Brief Description of the Service: Kirkwood is a detached, domestic style, property standing in large well tended gardens in Ben Rhydding on the outskirts of Ilkley. It is situated close to the top of a quiet cul de sac and is indistinguishable from the other family houses on the street. The driveway provides parking for several cars. A small parade of shops (including a post office) and the railway station is a short walk from the home. All bedrooms are on the ground floor and all offer single occupancy. The home offers a genteel, comfortably appointed environment for independently minded people and makes every effort to accommodate different tastes and interests. The home can accommodate older people of either sex but traditionally the occupants have been ladies. The operations manager works closely with the registered manager. NVQ training for staff is well underway, supplemented by a programme of general training covering a range of subjects relevant to the carers role. Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection carried out between 10.30 am and 4.20pm was undertaken by one inspector. The purpose of the inspection was to ensure that the home was operating and being managed to a satisfactory standard and in the best interests of the residents. During the course of the inspection the inspector examined a selection of records, spoke with staff, a visitor, the pharmacist, several residents, a visiting tutor, a candidate for a job interview and briefly inspected parts of the home. There have been no complaints about the home and no additional visits since the last inspection. What the service does well: The pre admission assessments give a good overview of what peoples needs are but needs to show what the home can do to prepare to meet the needs identified. Residents benefit from the daily handover meetings which keep staff up to date with changes. Some residents enjoy craft activities with a voluntary teacher who visits the home each week. This was seen to be a social occasion as well as being productive. The home provides a drinks trolley which allows people to have a pre or after meal drink if a part of their routine before entering the home. Mealtimes are social occasions served in a pleasant environment with well set tables. People can eat in their rooms if they so wish. A cold water dispenser in the dining room provides a self serve facility and staff serve hot drinks at regular intervals or at any time on request. The residents appreciate the fresh baking. Residents comments and views are listened to and action taken with consideration for the overall interests of the group. The high standard of décor and furnishing in the home and attention to small homely details creates a comfortable domestic atmosphere. Staff are well presented, pleasant and respectful. Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Pre admission assessments should include a summary which shows how the home will prepare to meet the needs at the point of admission. The work to bring all the care files up to date and consistent in layout must be given high priority. There must be evidence to show that care plans are reviewed monthly and more frequently in response to changing circumstances. Care plans must provide some guidance on social and recreational needs. The manager was able to describe how she worked with more withdrawn people but this was not documented for the benefit of less experienced staff. It is recommended that supervision be used as an opportunity to monitor and develop care plans and daily records. It is recommended that daily records make reference to the health care section of the file where more detailed information is recorded. There should be equivalent dish alternatives offered on the menu each day. Convenience foods are not a suitable alternative for the main meal of the day unless specifically requested. There must be evidence to show that staff receive formal training on adult protection. The design of commodes used in some rooms should be mindful of peoples’ dignity and in keeping with the standard elsewhere in the home. If doors are to be held open it must be by an approved hold open device linked to the fire alarm system. Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 7 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. Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 8 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 Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 9 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): 3,4 The homes pre admission gave a good picture of identified needs but did not demonstrate how the needs were to be met. EVIDENCE: A pre admission assessment done for a person due to be admitted to the home for respite care was inspected. The assessment had been completed in a way which gave a good picture of the person’s needs. As stated at the last inspection the assessment must show in the form of a summary or action plan how the home can meet the needs. This can then provide the basis of a care plan at the point of admission. Another care file inspected included an assessment by the funding authority. Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 10 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): 7,8,10 Staff are aware of the residents’ needs and there is good verbal communication amongst the staff group. Residents are treated with dignity and their privacy maintained. The process of bringing all care files into line must be completed EVIDENCE: Two care files were inspected and care plans examined. The files were sectioned to make information easy to find. The more recent care plan sheets showed the aim of each plan in the left hand column with the right hand column showing how to meet the aims. The review information was well documented and indicated that staff were referring back to the original care plan when describing progress. There must be evidence to show that reviews are carried at least monthly and have involved the views of the resident and or their representative. Staff respect the right of residents who wish to stay in their rooms, however there should be a plan of care to guide staff on how their social and recreational needs may be met. The outcome of contacts with health professionals was recorded in detail in the health care section of the file. More attention should be given to what is Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 11 written in the daily records to cross-reference with information written elsewhere in the file to ensure it is not overlooked. It was apparent that some staff are better than others at recording their own actions in response to residents’ care needs. It is suggested that monitoring and guidance on care planning documentation be included on the agenda for formal supervision. Staff are made aware of changes through a system of staff handover meetings but it was acknowledged that all the care files must be brought into line for consistency and to provide documentary evidence of the care being provided. Only one person has chosen to have a key to her bedroom. Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 12 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): 12,13,14,15 The home sets out to provide a satisfactory service and values residents’ comments. Residents are encouraged to be part of the decision making process and make choices about their lifestyle. Family, friends and visitors are welcomed at the home. Meals are served in pleasant surroundings but the choices provided on the daily menu should be reviewed . EVIDENCE: A craft teacher who has been visiting the home for five years was working with a group of residents in the dining room. This was a social event during which people in the group were knitting crocheting and plastic weaving. Some organised entertainments had taken place during the Christmas period. A drinks trolley is available if any of the residents want to have a drink before or with their meal. Staff are able to describe how they spend time with people who do not wish to socialise and examples of this were overheard but this is not recorded in the care plans as individual preferences. One person said she liked the radio but did not have a radio in her room. The manager said she would provide one. The manager stated she has a generous food budget There is a list in the kitchen of dietary dislikes and an alternative is provided. However, convenience chicken nuggets or vegetable burgers may be suitable Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 13 at tea time but are not a suitable alternative dish for the planned main meal of the day. Some residents had not been satisfied with some of the meat supplied to the home, though the pork steak sampled on the day of the inspection had flavour and was tender. The operations director had arranged a meeting between the meat supplier and some of the residents to enable them to express their views. Residents voiced their appreciation for the cook’s fresh baking. The dining room tables were laid out in a pleasing way and hot and cold drinks were regularly available. Staff should ensure that when they are serving drinks they do not handle biscuits and buns but offer choice from a plate. Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 14 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): 16,18 Residents are protected and feel safe living in the home. Residents are aware of the complaints procedure and how to use it. There must be evidence to show that staff have had formal training on adult protection. EVIDENCE: The manager applied early last year for formal training for staff in adult protection but this has not yet happened. The subject is covered as part of the interview process and supervision and a leaflet giving basic guidance is available. The manager must make arrangements for the training to take place. Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 15 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): 19,20,22,24,26 The home offers a clean, comfortable, domestic style environment for the residents. Specialist equipment is provided to reduce the risk of pressure sores. It is recommended that if commodes are to be used they be of a design which is discrete and in keeping with the standard of furnishing elsewhere in the home. The practice of wedging doors open compromises fire safety. Systems are in place for the upkeep and maintenance of the building. EVIDENCE: The home is pleasant comfortable and well maintained. Most bedrooms have an open, rural outlook. The garden is well kept and provides an outdoor sitting area. The single bedrooms do not have en suite facilities. Residents personal possessions were around them in bedrooms which can be locked but there was still only one person in the home who had a key. Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 16 It was of concern to note that several doors throughout the home were wedged open. It is appreciated that this is the preference of the residents but any door in the home, which is to be held open, must be fitted with an approved hold open device linked to the fire alarm system. An institutional style commode without a seat being used in one room was not up to the standard seen elsewhere in the home as it compromised the privacy and dignity of the occupant. It is recommended that when commodes are used they be of the type indistinguishable from a normal chair Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 17 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): 29,30 The home’s selection and recruitment practices protects residents. Training for new staff enables them to be able to understand and meet the needs of the service users. EVIDENCE: There were three care workers, the manager and a cook on duty at the time of the inspection with 17 people in residence. The manager and a senior care worker were interviewing for additional staff on the day of the inspection. It was apparent from discussion with an interviewee and the interview panel that the selection and recruitment process was thorough. Questions were based on each applicant’s completed form and notes taken during the interview. Both interviewers should take notes as discussed to ensure equality in the selection process. The staff were neatly dressed, pleasant and respectful towards residents. They were overheard talking to each other to explain their whereabouts and tasks, indicating good teamwork. A member of staff confirmed that the home has an NVQ programme with two staff enrolled to do the award. She was able to list the following topics covered on in house training:- Fire safety, moving and handling, cross infection, abuse leaflets, basic dementia, care plans. Staff are still awaiting formal training in adult protection. The manager agreed to follow this up with the adult protection unit. Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 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): 31,32,36,38 The manager has the skills and knowledge to provide effective leadership. Staff are well motivated, residents are consulted and their interests are safeguarded. The manager must ensure that fire safety procedures are followed at all times for the protection of residents. EVIDENCE: The manager and deputy have started working towards the NVQ4 management award. Staff are kept up to date with care needs through daily handover meetings between shifts and by looking at the care plans. A programme of staff supervision has been introduced and two senior staff have been booked on a supervision course in March. A standard format been developed for supervision and to identify training. It is recommended that this should include a review of progress since the last supervision, monitoring of a care plan and recording skills and an action plan. Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 19 Some doors are fitted with hold open devices linked to the fire alarm. In the interests of health and safety all doors which are to be held open must be fitted with a similar device, not wedged open. Staff are to undertake a health and safety training course in the next few weeks. Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 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 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 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 3 17 x 18 2 2 3 x 3 x 3 x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x x 3 x 2 Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 Page 21 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 OP4 Regulation 14.d Requirement The pre admission assessment must include information which states how the home is to meet the assessed needs All the care plans must be consistent in layout and provide documentary evidence showing residents’ preferences and how care is provided Staff must receive formal adult protection training Approved hold open devices must be fitted to all doors which are to be held open. Wedges must not be used in the interests of fire safety Timescale for action 31/03/06 2. OP7 15.(1)(3) 31/03/06 3. 4. OP18 OP38OP19 18 12,23 30/06/06 31/03/06 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 15 Good Practice Recommendations The choices available each day on the menu should be DS0000030148.V276711.R01.S.doc Version 5.1 Page 22 Kirkwood Care Home 2. 4 22 36 reviewed. Staff should ensure they do not handle biscuits and cakes when serving refreshments but offer choice in an appropriate manner Commodes should be discrete and in keeping with the furnishings elsewhere in the home It is recommended that supervision includes monitoring of care plans and the way information is recorded. Supervision should have an action plan as an outcome Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 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 Kirkwood Care Home DS0000030148.V276711.R01.S.doc Version 5.1 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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