Inspection on 22/08/05 for Kirkwood Care Home

This inspection was carried out on 22nd August 2005.

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 17/01/06

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 LS29 8BL Lead Inspector Sue Dunn Announced 22 August 2005, 9:30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 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 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 Mrs June Florence Jackson Care Home only 20 Category(ies) of Physical disability over 65 years of age (20) registration, with number of places Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 02/03/05 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 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection, which was announced, was undertaken by one inspector. The inspection started at 9.30am and finished at 4.30pm. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents. Comment cards were sent to the home before the inspection to give people the opportunity for anonymous feedback. Several of these were completed and returned. The inspector spoke with a number of residents, a visitor, a member of staff, the provider and the manager a selection of care files and records, including a pre inspection questionnaire completed by the provider, was examined, the main meal was sampled and the building was briefly inspected. What the service does well: What has improved since the last inspection? Progress has been made on introducing care plans which give guidance on each persons preferences and how they are to be supported. The care plans, which have been reorganised, are much improved but this work has not yet been completed. The content of the records of the reviews of care plans is more relevant to the care being given. The manager recognises the importance for the staff to have an understanding of each person’s past history in order to give care which centres Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 6 on the person. Pre admission assessments look at a full range of emotional as well as physical needs. Each person is valued for their individuality. A deputy manager is now in post to support the manager who has gained the respect and confidence of staff and residents. 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. Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4,5 People are able to make an informed decision about the home from the written information they receive and what they see when they visit the home. The pre admission assessments had improved but still need to include a plan of care which shows people how their needs are to be met. EVIDENCE: Several of the service users spoken with said they or their families had visited the home prior to admission. One person said she had stayed for a meal during the visit. A relative who had considered the home as she lived nearby said she knew immediately on entering the home that it was the right place for her mother. The manager has worked to improve the quality of the pre admission assessments. However the assessment of needs must include an action plan which states what the home will do to meet those needs on admission. Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Progress has been made towards improving the care plans. Residents care needs are met but this is not yet fully evidenced in all the care plans. The manager should make sure that staff are mindful of resident privacy at all times. EVIDENCE: The manager is gradually changing the layout of the care files with an improvement seen in those that have been completed. Further amendments may be needed in order to make sure the documentation works for staff in the interests of the people being cared for. The care files seen showed evidence that health care was satisfactory. A care plan from hospital giving guidance on pressure care was being followed. The registered provider is a nurse and provides training and advice for staff on health related topics. Two people and a relative said they had been very pleased with the level of care before and after periods in hospital. Contact with GP’s and district nurses was well documented. Care plans should be reviewed as needs change. Daily notes showed a person was becoming increasingly forgetful but there was no care plan to show how the individual was being supported. All the residents spoken with felt they were well cared for but two comment cards stated that the people concerned did not always feel their privacy was Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 10 respected. The manager should talk to residents and monitor staff practices to identify the circumstances when privacy may have been overlooked. Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Residents’ choices are respected and contact with family and friends is encouraged. Residents comments about the food are welcomed and any suggestions acted upon EVIDENCE: The new assessments gave a good background history of lifestyle preferences. The ladies in the home were unanimous in feeling ‘well looked after’. Those who wish, and can, go out with families, to church related events, and for walks. The garden offers a pleasant sitting area, which is used on warmer days. A craft instructor visits weekly, and entertainment and clothes parties take place. A visitor said she was welcome any time. One person wanted to stress that people are able to stay in their rooms if that is their wish and can keep in touch with friends and family by telephone. Talking books, crosswords and a range of newspapers provide stimulation. One person felt that there were not always enough newspapers to go round, though people have the option to order their own newspapers. The food was sampled and found to be tasty and hot though one person said she had not enjoyed the meal. The manager said the chef, who was not working that day is expected to seek the views of residents after each meal. One person said that a good range of savoury options for snacks was not always available. The manager was aware that there had been occasions at weekends when the full range of options had not been available and had introduced a Friday shopping list to make sure nothing was overlooked. Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 12 Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Complaints are dealt with appropriately but the manager should make sure that everyone has a copy of the complaints procedure. Overall, service users are protected from abuse with the majority of staff having some understanding of adult protection. EVIDENCE: The home has a complaints procedure and all the people spoken with said they found the manager approachable and felt they could express their views and have ‘differences of opinion’ without fear of repercussions. One person who returned a comment card was not aware of the complaints procedure. Staff have in the past had video training on abuse but there have been several staff changes since that time. The home has made a referral to The Bradford Adult Protection unit for further training on adult protection. It is recommended that the manager should talk through the adult protection procedures with staff whilst awaiting the training. Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,23,24,25,26 The home offers a comfortable, well-maintained environment for the residents. The manager is taking steps to make sure standards of cleaning are consistently high throughout the home EVIDENCE: The present owners have had to do a lot of work since purchasing the home to improve health and safety standards. This has delayed the work to install a shower which residents have said they would like to have. Communal areas have been upgraded to a high standard and are spacious and comfortable. Bedrooms are being redecorated and refurnished as they become vacant. One person has a key to her bedroom and others can if they wish. Each bedroom contained personal belongings and was arranged according to the preferences of the occupant. Overall the standard of cleaning was good but there was evidence that the cleaning in some of the bedrooms had been rather superficial with a build up of dust seen under wardrobes and on items of furniture. This was a source of Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 15 irritation to people who spent time in their rooms. The manager acknowledged that there had been some problems which she was trying to deal with. Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,30 Staff were polite and respectful. Staffing numbers and skills ensure that residents’ needs can be met EVIDENCE: The home employs a total of 12 care staff 5 of whom have achieved the NVQ award. Agency staff had been employed on four shifts during the weeks leading up to the inspection to ensure staffing levels were satisfactory for the needs of residents. In addition to topics covered as part of the induction programme for new staff and the NVQ award training has included first aid, food hygiene, fire safety, moving and handling, health and safety at work and risk assessing. Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36,37,38 The home is well managed and the manager is well able to discharge her responsibilities. She offers good leadership to the staff and ensures the residents are protected and cared for in a correct manner. EVIDENCE: The manager, who has a social work qualification has enrolled on the NVQ4 award course in Management. A deputy manager has recently been appointed who will also undertake the award. Residents and staff said the manager was well liked and inspired confidence. The manager has introduced a system of daily handover meetings, staff meetings and each member of staff has formal supervision. The home does not manage any personal allowances. Some people manage their own finances and others have the support of families or people appointed to manage their affairs. Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 18 The manager has done the fire trainers course and records showed that staff receive regular fire safety training updates. The home’s maintenance book gives a record of all maintenance and repair work with evidence that this is checked by the registered provider. Routine safety checks are done and recorded. Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x 3 3 3 3 Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 20 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 4 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 completed to give guidance to staff on how each persons care needs are to be met.A new plan of care must be introduced as needs change Staff must, through training, make sure that they are mindful of every residents right to privacy The standard of cleaning must be consistent in all parts of the home Timescale for action 31.11.05 2. 7 15.(1)(3) 31.03.06 3. 10 12(4) 18(1)c 23(1)d 30.11.05 4. 26 30.11.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 16 18 Good Practice Recommendations All service users should have a copy of the complaints procedure There should be evidence to show that all staff have been informed about the adult protection procedures whilst 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 21 Kirkwood Care Home waiting for the more formal training. Kirkwood Care Home 20050822 Kirkwood Care Home AN Stage 4 S30148 V192570 J52.doc Version 1.40 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley 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. 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