Inspection on 21/02/06 for Kirlena House

This inspection was carried out on 21st February 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

Kirlena House 18/10/08

Kirlena House 19/11/07

Kirlena House 20/07/07

Kirlena House 19/05/06

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 Andy McGuckin Unannounced Inspection 21st February 2006 01:30 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 Kirlena House DS0000013097.V284475.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. Kirlena House DS0000013097.V284475.R01.S.doc Version 5.1 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.V284475.R01.S.doc Version 5.1 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. 9th August 2005 Date of last inspection Brief Description of the Service: Kirlena House is a registered care home for the elderly accommodating up to 12 residents. It is located near Oxford in a suburban area, close to shops and transport facilities. The home itself is detached and set in its own grounds. The home provides 24-hour support for the service users and accesses appropriate external support to maintain the health of the service users accommodated. The home endeavours to meet all the assessed needs of the service users in a clear, open and person-centred manner. The home does not provide nursing care, and has a clear admissions policy. The home is managed and staffed by an experienced manager and staff are trained and supervised to enable them to provide the care and support needed by the residents. 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. Kirlena House DS0000013097.V284475.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection focusing on the health and social care needs of the residents and following up on previous requirements and recommendations. The inspector met with the proprietor and manager, toured the building, spoke informally to staff and residents and inspected core documentation required to evidence that minimum standards are being met. Requirements and recommendations made at the last inspection have been addressed. What the service does well: 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. Kirlena House DS0000013097.V284475.R01.S.doc Version 5.1 Page 6 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.V284475.R01.S.doc Version 5.1 Page 7 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): Standards contained in this section were not included in this inspection as they had been assessed as satisfactory at the last inspection. EVIDENCE: No standards in this section were inspected as they had previously been assessed as met at the last inspection. Kirlena House DS0000013097.V284475.R01.S.doc Version 5.1 Page 8 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, 9, 10, 11 Residents’ health and social care needs are being met. EVIDENCE: Evidence was found at the inspection, by reading five residents’ files, that individual health, personal and social care needs are being met. The home is now monitoring all falls as to date, time and location. The home has appropriate policies and procedures to manage the storage, recording and distribution of medication. A random selection of residents’ medication was inspected and found to be satisfactory. The inspector witnessed care being given and was assured that residents are treated with respect and that their privacy is being respected. Information is gathered and held on file as to of the wishes of residents following their death. Kirlena House DS0000013097.V284475.R01.S.doc Version 5.1 Page 9 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 provides both internal and external activities for those who are willing and able to participate. EVIDENCE: Residents are encouraged to maintain contact with relatives and friends from their past where appropriate. During the inspection the inspector witnessed visitors to the home being made to feel welcome. Residents are given choices and encouraged to maintain as much control over their lives as they are willing or able. On the day of the inspection residents were enjoying a music session. Activities are planned ahead on a monthly basis. The main meals for this home are prepared and transported from the sister home in heated containers. Previous feedback from residents and their families stated that meals are of a good standard. Drinks and snacks are prepared in the home’s kitchen. Kirlena House DS0000013097.V284475.R01.S.doc Version 5.1 Page 10 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, 17, 18 The home has a satisfactory complaints procedure. EVIDENCE: As is the case with the sister home, the size and management structure of the home ensures that concerns and complaints are dealt with at source and informally if possible. The home has a formal complaints procedure. The complaints log evidenced that one recent formal complaint had been dealt with to the complainant’s satisfaction. Evidence was found through reading case files and speaking to residents that their legal rights are being protected and that they are protected from abuse. Kirlena House DS0000013097.V284475.R01.S.doc Version 5.1 Page 11 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, 21, 22, 23, 24, 25, 26 The home is well maintained both internally and externally. EVIDENCE: The home is fit for purpose and is maintained in a satisfactory manner. Communal facilities are available, both inside and out. The home has sufficient washing and bathing facilities. Where specialist equipment is required, an assessment is undertaken by an external specialist trained to do so. Staff training then takes place to enable carers to use this equipment in a safe manner. Residents all have single rooms. As stated in previous inspection reports, many rooms do not have carpets and some rooms have metal-framed beds which, in the inspector’s opinion, give the rooms a very medical and institutional feel. Kirlena House DS0000013097.V284475.R01.S.doc Version 5.1 Page 12 Evidence was found that residents are able to bring their own small possessions with them. The home was found to be clean and fresh smelling on the day of the inspection. Kirlena House DS0000013097.V284475.R01.S.doc Version 5.1 Page 13 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): 27, 28, 29, 30 The home employs staff in sufficient numbers to meet the needs of its residents. Staff are trained and supervised to a satisfactory level. EVIDENCE: Evidence was found at inspection by reading all staff files that staff are trained and experienced to complete the tasks required of them. On the day of the inspection the rota showed that three staff were on duty in the morning, two in the afternoon and two in the evening/night. The proprietor and manager float between the two homes and can cover any gaps in service. References and documentation held on file were found to be satisfactory. Some files contain contracts where the hourly rate shows as less than the minimum wage. This was found to be an administrative error and will be amended to reflect the accurate rate. Evidence was found that appropriate police checks had been sought. Where special home office status was required, this could be found on file. All staff are being trained and training profiles are available for future training. The manager is currently undertaking the Registered Managers Award in Care. Kirlena House DS0000013097.V284475.R01.S.doc Version 5.1 Page 14 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): No standards in this section have been included in this report. EVIDENCE: All the above standards were assessed at the last inspection and found to be satisfactory. No changes have been made since the last inspection. Kirlena House DS0000013097.V284475.R01.S.doc Version 5.1 Page 15 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 X X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X x Kirlena House DS0000013097.V284475.R01.S.doc Version 5.1 Page 16 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. 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 OP24 Good Practice Recommendations The home should provide private accommodation for each service user, which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. Kirlena House DS0000013097.V284475.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Kirlena House DS0000013097.V284475.R01.S.doc Version 5.1 Page 18 - 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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