Inspection on 20/07/07 for Kirlena House

This inspection was carried out on 20th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 19/11/07

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 Catherine Kane Unannounced Inspection 20th July 2007 08:10 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.V339914.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.V339914.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.V339914.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. 19th May 2006 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 does not provide nursing care, and has a clear admissions policy. The home provides 24-hour support for the residents and accesses appropriate external medical and nursing services to maintain the health of the residents living here. 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.V339914.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 8.10am on Friday, 20 July 2007. The inspector was in the service for just over four hours. The inspection was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager that included an Annual Quality Assurance Assessment (AQAA) and any information that the CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection or who responded to questionnaires or surveys that the Commission had sent out. 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 owner’s wife, who is registered as manager of the other home owned and run by the proprietor and takes a lead role in the running of this home, was present at time of the inspection visit. Two night staff were coming off shift when the inspector arrived, four other members of staff came on duty for the morning shif - two care staff, a cleaner and the handyperson. The inspector spoke with eight of the nine residents. The inpsector was in the home while residents had breakfast. She saw how staff help residents look after and take their medicines. She also looked at residents’ care plans and other records kept in the home and made a tour of part of premises. The inspector would like to thank the owner and her staff team for their assistance with the inspection. She also thanks residents who shared their experience of this home and all others who returned surveys. What the service does well: The home has a friendly, relaxed atmosphere with positive relationships between residents and staff. Staff had a good understanding of residents’ support needs. Meals provided are generally good. Personal care and healthcare support provided in this home is good. The home would be able to meet the needs of individuals of various religious, racial or cultural backgrounds. Residents indicated that they like living in the home. Residents’ relatives or advocates make positive comments about this home. Kirlena House DS0000013097.V339914.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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.V339914.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.V339914.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): Standard 3. Standard 6 does not apply, as this home does not provide intermediate care. Quality in this outcome area is good. The home’s admission and assessment procedures ensure that individual’s needs are appropriately identified and met. Terms and conditions/contracts of stay at the home are available to all individuals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the visit the inspector viewed the pre-admission assessments for two residents who had moved into the home in the last year. These were comprehensive and detailed and indicated that the home would be able to meet their needs. At the time of the inspector’s visit there were three vacancies at this home. Kirlena House DS0000013097.V339914.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): Standards 7, 8, 9 and 10. Quality in this outcome area is good. The care planning system in place provides staff with the information they need. Medication procedures ensure that medication is administered to all individuals in a safe and appropriate way. People’s dignity and respect is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection the inspector viewed three residents’ care plans. All the care plans were well documented to reflect people’s individualised personal care needs, sleep patterns, accident and falls records, nutrition and diet, mobility and daily records of care provided. The plan is regularly reviewed and includes comprehensive risk assessments. Kirlena House DS0000013097.V339914.R01.S.doc Version 5.2 Page 10 The care plans included detailed records of health care appointments that people had attended and also visits of health care professionals to the home. The health care professionals include the general practitioner, dietician, chiropodist, dentist, optician and specialised health care professionals. Residents’ medicines are securely kept in a locked cabinet within a locked cupboard. The home uses a pharmacist produced medication administration record (MAR). Records seen were neat and well maintained. Most residents medicines are supplied in a pharmacist produced monitored dose system. Records were kept of staff assessed as competent to administer residents’ medicines. During the inspection one member of staff confidently demonstrated how a resident’s medicines are looked after and how residents are helped to take their medicines. Staff training records indicated that training regarding the safe administration of medicines was undertaken. From the evidence seen and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural backgrounds. Throughout the inspector’s visit staff were seen to be respectful, polite and attentive to residents’ well being and comfort. Kirlena House DS0000013097.V339914.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): Standards 12, 13, 14 and 15. Quality in this outcome area is adequate. People who use the service are able to exercise choice in their daily lives, maintain bonds with family and friends and take part in social, cultural, religious and recreational activities. The home provides healthy and balanced meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the visit the inspector spent time with several residents. Most were able to tell the inspector about their experiences of living in the home. Six residents returned surveys to the inspector, all indicated that they were happy living in the home. One resident said, “I am very happy here and think most people are.” The home keeps a note of activities provided for residents. One resident told the inspector that staff do spend time with them to play games, hula-hoops or cards. Other residents like to chat, read newspapers, watch TV or listen to music. One resident said, “We don’t go out – people will go to the shops for you.” Kirlena House DS0000013097.V339914.R01.S.doc Version 5.2 Page 12 Of the six residents who returned surveys, when asked ‘Are there any activities arranged by the home that you can take part in?’ one resident responded ‘always’, four responded ‘usually’ and one responded ‘sometimes’. Three residents’ relatives returned surveys to the inspector and she spoke by telephone with one resident’s relative. One relative commented, “Provides care and support at a level appropriate to individual residents in a friendly and secure environment.” Another relative commented, “Makes YY feel it is her home.” Another relative said, “I can only say good things about this home.” When asked in the survey ‘How do you think the care home can improve?’ two relatives commented on activities. One commented, “Provision of a greater range of activities to stimulate the more lucid residents would be appreciated.” A recommendation to review the range of activities available to residents was made at the last inspection. Feedback from residents and relatives indicates this could be improved further. Residents’ spiritual and religious beliefs are respected. One resident attends church regularly, accompanied by the owner, and a local church group visits the home once a month. The inspector was in the home at breakfast time. Residents are able to choose if they wish to have breakfast in the dining room or in their bedrooms. The home continues to transport prepared main meals from the proprietor’s other care home situated nearby. From menu plans seen, a varied menu is provided and residents’ preferences and special dietary needs are catered for. When asked in the CSCI survey ‘Do you like the meals in the home?’ two residents stated ‘always’ and four residents stated ‘usually’. Kirlena House DS0000013097.V339914.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): Standards 16 and 18. Quality in this outcome area is poor. People who use the service are able to express their concerns and have access to a complaints procedure. They are protected from abuse and have their rights protected. Staff attend safeguarding people training. However, the home’s omission to undertaking its own Criminal Records Bureau (CRB) checks on new staff could potentially place residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear complaints procedure. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. Information provided by the home prior to the inspection visit indicated that one complaint had been received since the last key inspection. The owner was able to provide details of the complaint and action taken to resolve the issue to the complainant’s satisfaction. In written comments received in surveys regarding the home’s complaints process five residents indicated that they ‘always’ knew who to speak to if they were not happy. One resident commented, “If I had any problem I will speak to the Head of Home.” Kirlena House DS0000013097.V339914.R01.S.doc Version 5.2 Page 14 Information provided by the home prior to the inspection visit indicated that there were no safeguarding adults referrals under local multi-agency procedures since the last inspection. The home has an updated safeguarding adults and protection from abuse policy, which is available to staff in order to safeguard people in their care. Staff spoken with during the inspection demonstrated an understanding of the procedures for safeguarding adults. Staff training records detailed that staff receive awareness training regarding safeguarding vulnerable adults. The Commission has received no information relating to safeguarding adult issues since the last inspection. In information provided by the home prior to the inspection visit the home declared that it will “Ensure that all CRB checks are carried out immediately on employing staff”. This was seen to not be the case for one new member of staff recruited in February 2007 who started work in the home with neither a CRB disclosure nor POVA 1st check undertaken by the home. Clear guidance is available to homes on the procedures if it is essential for them to start new staff while awaiting CRB disclosures. These were not followed. (See also Standard 29). The home is currently considering renewing CRB checks on existing staff after three years. Kirlena House DS0000013097.V339914.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is adequate. The overall quality of furnishings and fittings in this home is good, but old and well worn. The home was tidy and generally clean at the time of the inspection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspector’s visit the maintenance person who carries out general repairs in this home and at the proprietor’s other home was on the premises. The owner stated that the home does not have a renewal plan for the home but furniture and equipment is replaced when necessary. While the furniture seen in the lounge and dining room was functional, it was past its best. A shower chair in a ground floor bathroom repaired with tape had torn upholstery, leaving a sharp edge exposed. This needs to be replaced. Kirlena House DS0000013097.V339914.R01.S.doc Version 5.2 Page 16 The home had a high standard of cleanliness. The owner took prompt action to address a strong odour of urine experienced in one WC on the ground floor. Kirlena House DS0000013097.V339914.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is poor. The number and skill mix of staff is consistent and generally meets the care needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection visit the inspector spoke with two members of staff. Both staff had been recruited abroad. The home has a core of well-established staff that understand residents’ needs and they relate well to. Staff commented that morale is good. The relative of a resident commented, “Frequent turnover of staff can make it difficult.” Generally, the recruitment process is thorough. The inspector viewed three staff files. These were well organised but the home’s omission to undertaking its own CRB checks on all new staff could potentially place residents at risk. (See Standard 18). The home keeps a record of training completed by staff; staff spoken with confirmed details of the training they have undertaken. Information provided by the home prior to the inspection stated that three of the 12 permanent care staff all have completed a relevant National Vocational Qualification (NVQ) at Level 2 or above. This home has not achieved the national target of 50 of staff trained to NVQ Level 2 or above. Kirlena House DS0000013097.V339914.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): Standard 31, 33 35 and 38. Quality in this outcome area is adequate. The home is well established and the proprietors manage and run the home in the best interests of the people who use the service. People’s safety, financial protection and welfare is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The atmosphere in the home was calm and orderly. The pace of the home was designed to meet the needs of the individuals living at the home and there was no sense of hurry. It was evident through observation and talking with people who use the service, and staff, that the owner had good knowledge about managing the care home and had the skills and experience to ensure the safety and well being of all persons in the home. However, the nature of the Kirlena House DS0000013097.V339914.R01.S.doc Version 5.2 Page 19 complaint received by the home in June 2007 was such that a notification to the Commission should have been made. The owner provided details of the quality assurance survey that included the views of residents and their family representatives or advocates, with the outcomes and plans to address any issues raised. The home completed the comprehensive Annual Quality Assurance Assessment (AQAA) where it outlined the areas where it was felt the home does well and reflected on the areas where it was felt that the home could improve, and measures have already been put in place to address these. The home has sound policies and procedures in line with current thinking and practice. Efficient systems are in place to monitor staff adherence to policies and procedures during their practice. The home works to a clear health and safety policy and checks take place to ensure that the home meets relevant health and safety requirements and legislation. Records kept were good and are routinely completed. Where issues have been identified these have been acted upon successfully to ensure that residents’ care is not compromised. Kirlena House DS0000013097.V339914.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 X 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 1 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Kirlena House DS0000013097.V339914.R01.S.doc Version 5.2 Page 21 No 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 OP18 Regulation 19(7) Requirement The registered person must ensure that CRB checks are carried out for all new staff prior to them starting work or with POVA 1st checks and appropriate supervision arrangements in place. Replace or repair damaged shower chair in ground floor bathroom. Timescale for action 31/08/07 2. OP19 23(2)(c) 31/08/07 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. Refer to Standard OP12 Good Practice Recommendations Review the range of activities available for residents with dementia and consider more flexible and ‘ad hoc’ ways of engaging residents in activities and social opportunities appropriate to their abilities and interests. Notifications required under the Care Homes Regulations 2001, Regulation 37 should be made without delay. 2. OP31 Kirlena House DS0000013097.V339914.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Oxford Office Burgner House 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. 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