Inspection on 09/08/05 for Kirlena House

This inspection was carried out on 9th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 21/02/06

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 Kennington Oxford OX1 5NZ Lead Inspector Andy McGuckin Unannounced 09 August 2005 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. Kirlena House H57-H08 S13097 Kirlena House V243441 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Kirlena House Address 18 Kennington Road, Kennington, Oxford, OX1 5NZ 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) 01865 730510 Mr Vedenath James Audit Care Home 12 Category(ies) of OP; DE(E); PD(E) registration, with number of places Kirlena House H57-H08 S13097 Kirlena House V243441 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The total number of persons that may be accommodated at any one time must not exceed 12. Date of last inspection 23 November 2004 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 H57-H08 S13097 Kirlena House V243441 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the afternoon of the inspection of the company’s sister home’s morning inspection and many of the findings from that report are duplicated in this report as they apply to both homes. The inspector toured the building and no health and safety issues were identified. The inspector interviewed two members of staff and spent time in discussion with the proprietors and manager. Documentation required for the inspection was viewed and case tracking was undertaken on four residents. All staff files were inspected and requirements will made made in the main body of this report. On the day of the inspection there was a very happy atmosphere in the home as there was a live music recital taking place. The audience was made up of residents, families, friends and children. Regular external entertainment is provided. Many of the home’s residents are able to access external entertainment and remain in contact with family and friends. The inspector would like to thank the management, residents and staff of the home for their co-operation throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: The registered manager must ensure that the home’s recruitment policy is reviewed to take into account translation of documentation attesting to overseas applicants. The registered manager must ensure that all references are directed specifically to the home and are for the position advertised. Staff contracts must specify the hours and location that staff are required to work. The Kirlena House menu must reflect the actual choice of food available on that day. Kirlena House H57-H08 S13097 Kirlena House V243441 090805 Stage 4.doc Version 1.40 Page 6 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 H57-H08 S13097 Kirlena House V243441 090805 Stage 4.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 Kirlena House H57-H08 S13097 Kirlena House V243441 090805 Stage 4.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) 1, 2, 3, 4, 5, 6. The home provides prospective service users with sufficient information on which to make an informed decision. EVIDENCE: The inspector was shown the home’s Statement of Purpose and Service User Guide. These documents outline what the home can and cannot provide. They are written in plain English and are easily understood. Each resident has a written contract/terms and conditions. The residents contract is signed by the resident or his/her advocate. The manager or proprietor assesses all prospective residents prior to admission. Admission is dependant on a mutual agreement that the home can meet the resident’s needs. Where it is discovered that the home is not meeting the resident’s needs, a review meeting is held involving all interested professionals, family or advocate. Friends and relatives are encouraged to maintain contact with residents and prior feedback from relatives indicated that they are made welcome when visiting the home and can visit at all reasonable times. Kirlena House H57-H08 S13097 Kirlena House V243441 090805 Stage 4.doc Version 1.40 Page 9 An individual care plan is drawn up stating what the residents care needs are and stating how the home will meet them. Care plans are reviewed regularly. Kirlena House H57-H08 S13097 Kirlena House V243441 090805 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10, 11. Evidence was found at the inspection by reading residents’ files, and from prior feedback from residents and their relatives, that residents’ health and social needs are being met. EVIDENCE: Residents’ files are set out in a way that would enable carers to have a clear idea of what was expected of them. The home has appropriate policies and procedures to manage the storage, recording and distribution of medication. The inspector witnessed care being given and was assured that residents are treated with respect and that their privacy is being respected. Information is now being gathered to inform the home of the wishes of residents following their death or serious illness. Kirlena House H57-H08 S13097 Kirlena House V243441 090805 Stage 4.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 are encouraged to maintain their social, cultural and recreational needs. EVIDENCE: Residents of the home are, in the main, very independent and require basic care. They are able to take full advantage of many of the social, cultural and recreational activities provided by the home. Residents are encouraged to maintain contact with relatives and friends from their past where appropriate. 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 the menu at Mon Choisy did not match the food being provided. The inspector was informed that the range and choice presented on the menu was not available. The inspector was informed that if a resident requested something different, then it would be provided. As this home is supplied with the food from Mon Choisy, the inspector concluded that this was also the case for Kirlena House. The registered person must ensure that the day’s recorded menu reflects the actual meal provided on the day and is amended to reflect any changes. Kirlena House H57-H08 S13097 Kirlena House V243441 090805 Stage 4.doc Version 1.40 Page 12 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, 17, 18, The organisation has formal processes for making a complaint or compliment. EVIDENCE: The size and management structure of the home ensures that concerns or complaints are dealt with. The home has a formal complaints procedure. No complaints have been logged for some time. Residents spoken to stated that if they had a complaint they would go to the proprietor or manager and felt confident that it would be resolved. Evidence was found through reading case files that residents’ legal rights are being protected and that they are protected from abuse. Kirlena House H57-H08 S13097 Kirlena House V243441 090805 Stage 4.doc Version 1.40 Page 13 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, 29, 21, 22, 23, 24, 25, 26. The home is well maintained and provides a safe environment for its residents. 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. Many rooms do not have carpets and some rooms have metal-framed beds which, in the inspector’s opinion, gives the room a very medical feel. Evidence was found that residents are able to bring their own small possessions with them. On the day of the inspection the home was clean and free of odour. Kirlena House H57-H08 S13097 Kirlena House V243441 090805 Stage 4.doc Version 1.40 Page 14 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, 29, 30. Staff have the appropriate training and experience to provide for the needs of the residents. EVIDENCE: Evidence was found at inspection that staff are trained and experienced to complete the tasks required of them. The inspector read all staff files, case tracking past experiences, references and police checks. Documentation found in the files varied in the quality and type of information required. Documentation could still be found in non-English formats and many references were addressed “To whom it may concern“. The registered manager must ensure that all references are for the job advertised and that the reference request is addressed to the proprietor or manager. 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. Kirlena House H57-H08 S13097 Kirlena House V243441 090805 Stage 4.doc Version 1.40 Page 15 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, 34, 35, 36, 37, 38. The business is run in a professional manner with the home being managed by an experienced competent manager. EVIDENCE: The registered manager is experienced and trained to manage the care provision offered by the home. The registered manager is supported to do this by a staff group of sufficient numbers and experience in the care of the elderly. There is much evidence of the proprietor’s involvement in the home to support the manager. The home has sufficient policies and procedures to assist in the protection of potentially vulnerable adults. The home is managed in a professional manner and the inspector was informed that it was financially sound. Accounts are available for inspection if required. Kirlena House H57-H08 S13097 Kirlena House V243441 090805 Stage 4.doc Version 1.40 Page 16 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 3 3 3 3 3 3 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 2 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 Standard No 16 17 18 Score x 3 3 3 3 3 3 3 3 3 3 Kirlena House H57-H08 S13097 Kirlena House V243441 090805 Stage 4.doc Version 1.40 Page 17 Yes 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 15 Regulation 17 Requirement The days menu must reflect the actual meal being taken. Changes must be reflected on the days menu. Documentation required for the safe recruitment of staff must be specific to the job and home. References should not be addressed To whom it may concern Timescale for action 21/9/05 2. 26 19 21/9/05 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. Refer to Standard 24 Good Practice Recommendations The home should review all bedrooms where lino is not agreed as a part of the care plan. Where beds are to be replaced consideration should be given to the use of domestic style beds. Kirlena House H57-H08 S13097 Kirlena House V243441 090805 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection Burgner House, 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 H57-H08 S13097 Kirlena House V243441 090805 Stage 4.doc Version 1.40 Page 19 - 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. 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