Inspection on 19/11/07 for Kirlena House

This inspection was carried out on 19th November 2007.

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

Kirlena House 18/10/08

Kirlena House 20/07/07

Kirlena House 19/05/06

Kirlena House 21/02/06

Kirlena House 09/08/05

Kirlena House 23/11/04

Kirlena House 21/09/04

Kirlena House 12/01/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Kirlena House 18 Kennington Road Oxford OX1 5NZ Lead Inspector Kate Harrison Unannounced Inspection 19th November 2007 2:15 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 Kirlena House DS0000013097.V352614.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 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. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirlena House Address 18 Kennington Road Oxford OX1 5NZ 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) 01865 730510 enquiries@auditcare.com Mr Vedenath James Audit Mrs Ellen Audit Mr Vedenath James Audit Care Home 12 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (1) Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 12. 20th July 2007 Date of last inspection Brief Description of the Service: Kirlena House is a registered care home for older people accommodating up to 12 residents. The home is located near Oxford in the village of Kennington, close to shops and transport facilities. The house itself is detached, with a patio area and large attractive garden at the rear. There is one shared bedroom and ten single bedrooms - all but one of the rooms have en-suite WC and hand basins. There is lift access to the first floor. The ground floor lounge overlooks the garden and there is a separate dining room. The home provides 24-hour support through the care staff and does not provide nursing care. Kirlena House is the smaller of two homes privately owned by the same proprietors and in close proximity to each other. The home shares its policies and procedures with its sister home, Mon Choisy. The current range of fees is between £464 and £555 per week. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’, and was the second inspection visit this year. We arrived at the service at 14.15 and spent 3.5 hours in the home. This inspection was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager through the Annual Quality Assurance Assessment completed earlier in the year , and any information that we had received about the home since the last inspection. We saw most areas of the home and looked at records and documents relating to the care of the residents. There were nine people living at the home at the time of the visit. We asked the views of some of the people who use the service and those who responded to our questionnaire. The inspector looked at how well the service was meeting the standards set by the government and has, in this report, made judgements about the standard of the service. The proprietor visited during the inspection, and his wife, who is registered as manager of the proprietor’s sister home nearby and who takes a lead role in the running of this home, was present for most of the inspection visit. From the evidence seen and comments received we consider that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. What the service does well: What has improved since the last inspection? Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 6 The recruitment procedures have improved, and a new shower chair has been provided. More training for staff has been provided. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home carries out a pre-admission assessment of need to make sure that the home can meet the individual’s needs. EVIDENCE: A senior person at the home carries out the pre-admission assessment for new individuals wishing to be admitted, and gathers as much information as possible before visiting the individual. The pre-admission assessment focuses on the needs of the individual, and whether the home can meet the needs. Records seen show that a careful assessment is made with the involvement of the individual where possible. Individuals and their families can visit the home and the individual can move in on a trial basis, before the judgement is made about moving in permanently. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care plans of individuals living at the home are known and addressed, in a respectful caring way. EVIDENCE: The inspector saw care plans showing the individualised care needs of two individuals. The care plans included clear details of how all the personal care needs would be met, and showed that nutritional assessments were conducted so that the nutritional needs of individuals were known and addressed. Details of visits by healthcare professionals are also recorded. The care plans are regularly reviewed and audited. People living at the home say that staff listen to what they say, and that they receive the medical support they need. The home has a medication policy, and only trained members of staff administer the medication. The medication is delivered weekly by a local pharmacist, and is stored securely. All the medication records seen were completed fully. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 10 The staff members understand the needs of those living at the home, and were seen to treat the individuals with respect. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home can receive visitors and have some opportunities to take part in activities, though it is not clear that they have often opportunities to go out. EVIDENCE: The home supports individuals to keep in touch with people who are important to them, and there are no unreasonable restrictions on visiting. Staff members offer a variety of activities over the week and weekends, and on the inspection visit some individuals were involved in playing a game of bingo. A recommendation was made at the last inspection about reviewing the range of activities available for residents with dementia, and to consider more flexible and ‘ad hoc’ ways of engaging residents in activities and social opportunities appropriate to their abilities and interests. There was no clear evidence available that a review had taken place, or that activities were available for people with dementia, and this previous recommendation remains (amended) in this report. Records are kept of those activities enjoyed by individuals, and one individual enjoys playing the home’s piano. There are regular ‘prayer and praise’ services at the home, provided by a local church. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 12 It is not clear that regular opportunities are offered for the people living at the home to go out, and it is not clear that if individuals wanted to go out, that there would be staff members available to take them out. Regular opportunities to go outside should be provided for the people living at the home. One individual said that she was happy at the home, and she liked how ‘the girls’ looked after her. Individuals said that they enjoyed the food, especially lunch. Lunch is prepared at the sister home nearby, and breakfast and supper is prepared in the home’s kitchen. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home can make a complaint and are protected from harm by the home’s procedures. EVIDENCE: The home’s complaints procedure includes timescales for replying to a complaint, and is displayed in the home. All the people living at the home have a copy of the procedure. No complaints have been received at the home since the last inspection, and no complainant has contacted us with information concerning a complaint made to the service since the last inspection. New staff members receive information about safeguarding the people living at the home during the induction period, and become familiar with the home’s safeguarding procedures. Further training is provided for all staff members. We have received no information relating to safeguarding adult issues since the last inspection. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is safe and homely, and would benefit from updating of the communal areas. EVIDENCE: The home is comfortable and homely. People living at the home said that the home is clean and tidy. The home has a system for logging and attending to daily repairs and general upkeep, so that issues are attended to in a timely way. Private rooms are updated regularly, to suit individual’s preferences. The home’s management is considering a development plan to ensure that the home’s furniture and communal areas are updated in a planned way. The lime scale deposits seen on the bathroom fittings during the inspection visit were quickly removed, and quality checks should be in place to make sure that the standard of cleanliness is maintained. The environmental health officer visited the home during October 2007, and had no recommendations to make. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 15 The home has an infection control policy and staff members are updated on how to prevent the spread of infection. The care staff members manage the home’s laundry, and protective clothing is supplied when necessary. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is not clear that enough staff members are available to meet all the needs of the people living at the home. EVIDENCE: The home keeps a staff members rota showing who is on duty over the 24 hours, and this shows that at times two members of staff are available to meet the needs of the residents. The care staff are also responsible for laundry and other tasks. It is not clear how the needs of the people at the home would be met if one member of staff was needed to escort an individual to an appointment, or if some individuals wanted to spend time in the garden or in the nearby village. The staff rota should show what arrangements are in place to make sure that some individuals can leave the home escorted, while enough staff members are at the home to meet the needs of the other people living there. Of the 11 care staff members at the home, 4 have a National Vocational Qualification (NVQ) Level 2 (or above) in Care, and one person is undertaking the course. Although some of the staff members are qualified nurses in their country of origin, they do not have the necessary information available at present to show an equivalent qualification to NVQ. This means that the home has not yet attained the national minimum standard of 50 trained staff in the home, though may do so soon. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 17 The home’s induction programme is to the required standard, and the home has a staff members’ training programme. Since the last inspection, staff members have attended 16 training days, in first aid, food safety, nutrition, continence and fire awareness. The home recruits new staff members from abroad and uses an agency to manage the process. The home’s application form is a key part of the recruitment process, but all parts of the form are not always properly completed. In one form there were no referee names and no date when the application form was completed. This makes it difficult to verify the authenticity of references, and the home should make sure that applications to work at the home contain all the necessary information. Following the inspection of 20th July 2007 a requirement was made that all new staff have CRB clearance or POVA 1st checks prior to them starting work. One new member of staff who started work two weeks after the last inspection did so before a Criminal Record Bureau clearance or POVA First check had been received. Other new staff members had the appropriate checks in place before starting work. The proprietor explained that this was an administrative oversight and it was noted that it had occurred while the requirement timescale given for compliance was valid. The proprietor confirmed that since then the administrative processes have been strengthened and it is very unlikely to happen again. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 and 38. Quality in this outcome area is adequate. The proprietors have made some improvements to the home since the last inspection visit, though not all the recommendations have been acted on and more have been made at this visit. Peoples’ safety and financial protection are promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The proprietor is the registered manager for the service, and has completed the Registered Manager’s Award. Although improvements have been made to the home since the last inspection visit not all the recommendations have been implemented, and further recommendations have been made at this inspection visit. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 19 A quality assurance exercise was carried out this year and the views of healthcare professionals were requested. The results are being collated, and it is intended to publicise the main findings. Other quality checks, such as for cleaning, need to be in place. Some petty cash is kept securely for people who are unable to manage independently, and records of transactions are kept and audited weekly. A senior member of staff is responsible for the health and safety aspects of the home, and has attended fire risk assessment training. A fire risk assessment has been carried out and an evacuation plan is in place in the event of fire. The home has a health and safety policy statement and provides training for staff on safety topics, such as moving and handling. Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP12 Good Practice Recommendations Seek advice from The Alzheimer’s Society or other similar organisation about the range of activities available for people with dementia. This recommendation remains from the inspection of July 20th 2007. Regular opportunities to go outside should be provided for the people living at the home. Regular quality checks should be in place to make sure that the standard of cleanliness is improved. The staff rota should show what arrangements are in place to make sure that some individuals can leave the home escorted, while enough staff members are at the home to meet the needs of the other people living there. The home should make sure that application forms to work at the home contain all the necessary information. 2 3 4 OP12 OP26 OP27 5 OP29 Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kirlena House DS0000013097.V352614.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!