Care Home: Kirby House Mental Nursing Home

What has improved since the last inspection? Medication Administration Record (MAR) sheets were correctly completed. A copy of the action plan based on the occupational therapists report was submitted to the Care Quality Commission (CQC) to demonstrate the action being taken to meet people`s needs, in relation to the environment.Kirby House Mental Nursing HomeDS0000017677.V375424.R01.S.docVersion 5.2Page 7This home provides information documents that are specific to the individual home, however some areas of this document presently require amendments. People living in Kirby House know who to speak to within the home if they have concerns however information about who to contact outside the home was incorrectly detailed at the time of the inspection. The manager made these amendments to the document the day after the inspection. What the care home could do better: The home is generally clean, comfortable and well maintained however some areas of the home may not be suitably equipped for residents as their conditions deteriorate. However this is not adversely affecting anyone currently living in the home. We looked at staff supervision records. Although there is a system in place, supervision is rather sporadic. The manager currently only has six hours a week allocated to management/office duties, the rest of her time is spent working `hands on` with the residents, and she does not receive any administration support. Therefore she has to prioritise duties for this time, and some areas are consequently not receiving the attention they require. Reference was made to this problem in the last two inspection reports, however to date there is no evidence to suggest that efforts have been made to resolve it. It now becomes a priority as requirements from the previous inspection relating to updating documents, have not been adequately addressed and therefore remain unmet. Key inspection report CARE HOMES FOR OLDER PEOPLE Kirby House Mental Nursing Home 135 West Street Dunstable Bedfordshire LU6 1SG Lead Inspector Mrs Louise Trainor Unannounced Inspection 18th May 2009 08:15 DS0000017677.V375424.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirby House Mental Nursing Home Address 135 West Street Dunstable Bedfordshire LU6 1SG 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) 01582 662609 01582 476945 kirbyhouse@schealthcare.co.uk Southern Cross Care Homes Limited Ms Neo Loate Care Home 7 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (7) of places Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user can be placed in the home under the age of 65 years. 20th June 2008 Date of last inspection Brief Description of the Service: Kirby House provides care and support to six older people with mental health care needs. Southern Cross Care Homes Limited, a large national healthcare provider own Kirby House. Kirby House is a small home situated in a residential area near Dunstable town centre in the county of Bedfordshire. It is an extended family type house, with five single bedrooms and one shared bedroom. There are bedrooms on both floors. Access to the first floor bedrooms is via the stairs, which means that people need to be independently mobile. There is a shared dining and sitting room and a small garden area to the front and side of the property. There is a small parking area to the rear and there are good public transport links and a range of local amenities within walking distance of the home. The fees for this home presently range from £675.00 to £995.00 per week. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection was carried out in accordance with the Care Quality Commission (CQC) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. This was the first Key Inspection this year for this service. The last inspection was carried out in June 2008. This visit was carried out on the 18th of May 2009, by Regulatory Inspector Mrs Louise Trainor, between the hours of 08:15 and 13:00 hours. The homes manager was on duty when we arrived, and was present for the whole inspection. Feedback was given both during, and on completion of this inspection. During this inspection we tracked the care of two people who live in this home. This involved reading their records and comparing what was documented, to the care that was being provided. We also looked at the pre admission documentation in place in this home, and the manager was able to demonstrate the pre admission processes that she uses. However as all the present residents have lived in Kirby House for at least nine years, the current documentation had not been used for them. Documentation and records relating to: staff recruitment, training and supervision, medication administration, complaints, quality assurance and health and safety in the home were also examined. We also spent some time in the communal areas of the home, talking to staff and residents and observing the care practices that were carried out during this four and three quarter hour inspection. A full tour of the premises also took place. We would like to thank everyone involved for their support and assistance during this visit to the home. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 6 What the service does well: The manager was able to discuss and demonstrate the processes she is using to assess any potential residents. Care plans had been completed in sufficient detail to ensure that staff could provide consistent care. They included personal preferences and had been reviewed regularly to address any changing needs as they occurred. There was a very relaxed and familial atmosphere in the home. All the residents that we spoke to were very happy, and very satisfied with the way they are cared for. Two people that we spoke to referred to the staff and other residents as their family. The home has a strong commitment to enabling residents to develop and maintain their skills. The staff practices promote individual rights and choices, but also consider the protection of individuals in supporting them to make informed decisions. People in this home have confidence in the staff that care for them, they know the staff well and can communicate with them freely. Accurate job descriptions clearly define the roles and responsibilities of staff. The recruitment process in robust and the manager is aware of any gaps in training, which need to be addressed. The manager has the required qualifications and experience and is competent to run this home. She has a clear understanding of the key principles and values of the home, and the residents are central to shaping the delivery of service. The home is run with the residents best interests at the central focus. Their wishes and needs are undoubtedly a priority in this home. All the records that we looked at relating to residents care, and health and safety in the home, were accurately completed. Risk assessments were in place and being kept under review. What has improved since the last inspection? Medication Administration Record (MAR) sheets were correctly completed. A copy of the action plan based on the occupational therapists report was submitted to the Care Quality Commission (CQC) to demonstrate the action being taken to meet people’s needs, in relation to the environment. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 7 This home provides information documents that are specific to the individual home, however some areas of this document presently require amendments. People living in Kirby House know who to speak to within the home if they have concerns however information about who to contact outside the home was incorrectly detailed at the time of the inspection. The manager made these amendments to the document the day after the inspection. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 8 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 Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 People using the service experience adequate quality outcomes in this area. This home provides information documents that are specific to the individual home, however some areas of this document presently require amendments. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This home has a Statement of Purpose in place, however it is presently under review, as the senior management structure for this home has changed over recent months, as have the Care Quality Commission details. These all require amending. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 10 Each resident that lives in the home has a Service User File. This contains information relating to the homes Philosophy of Care, core policies and procedures, facilities available, fees, an individual Activity Framework, consent forms, and complaints. These are signed by the individual residents to indicate that they have read, or have had the document explained to them. There were however some details which are out of date and in need of review to ensure information is correct. All the residents that presently live in Kirby House have done so for at least nine years, therefore pre admission documentation has changed somewhat since the last admission to the home in 2002. However there is presently one vacant room in the home and the manager was able to discuss and demonstrate the processes she is using to assess any potential residents. She informed us that since March this year she has assessed four prospective residents, none of which have been suitable. It is important that the home are sure they can meet every individuals needs, but also that anyone coming into the home is compatible with the current residents, as this is a very small home and the residents see themselves as a family. This home does not offer an intermediate care service. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 People using the service experience good quality outcomes in this area. Care plans had been completed in sufficient detail to ensure that staff could provide consistent care. They included personal preferences and had been reviewed regularly to address any changing needs as they occurred. Medication Administration Record (MAR) sheets were correctly completed. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During this inspection we looked at the personal files of two of the residents who live at Kirby House. Files were tidy and generally well organised. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 12 Care plans were well written, and contained sufficient detail to ensure that staff could deliver care with continuity. Both of the files that we looked at contained numerous care plans ranging from personal care and moving and handling, to Mental Health issues and social activities. These were all being reviewed at least monthly and changes in needs addressed efficiently and effectively. One resident had recently sustained a fracture of her upper arm whilst out walking. A care plan has been formulated to address how her care has had to be adapted, and detail of the present level of assistance required, has been clearly identified. For another resident, Mental Health issues were the primary concern, and there was clear information and instructions for staff, to ensure that this resident was reassured, supported and given certain responsibilities, which played an important part in maintaining her mental stability. For both of these residents there were risk assessments relating to Moving and Handling, nutrition and falls, and additional risk assessments relating to the individuals, such as going out alone or risks relating to medical conditions. The files that we looked at also contained a sheet, where residents had identified how and where they would like to be cared for in the end stages of their lives. There was a very relaxed and familial atmosphere in the home. All the residents that we spoke to were very happy, and very satisfied with the way they are cared for. Two people that we spoke to referred to the staff and other residents as their family. One resident told us. “I ve been in twelve different homes and this is the best. The food is lovely and the staff are lovely, I can’t praise them enough, it’s such a happy unit, one big family”. The ‘closeness’ of these residents was also reflected in their general well being. The manager told us that one resident in particular had deteriorated in condition mentally since another resident, who she was close to, had had to move to another home as the environment in Kirby House was no longer suitable for her. The manager recognises, and is very sensitive to these issues and addresses them effectively. We examined the Medication Administration Record (MAR) sheets for all of the residents presently living in the home. These had all been correctly completed with signatures and omission codes where appropriate. Where variable doses were prescribed, the dosage given was identified. All the medication dispensed from blister packs reconciled correctly as did those dispensed from boxes. There are presently no Controlled Drugs (CD)’s in use in this home, however there is appropriate storage facilities and a CD register in place. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People using the service experience good quality outcomes in this area. The home has a strong commitment to enabling residents to develop and maintain their skills. The staff practices promote individual rights and choices, but also consider the protection of individuals in supporting them to make informed choices and decisions. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is presently no activity coordinator in post at this home however residents do have individual programmes / routines, in which all care staff are involved. Initially, on the day of this inspection, all five ladies currently residing in the home were present, and some were keen to talk to us about their routines and Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 14 activities. One told us about how she makes her own bed and is responsible for keeping her room clean and tidy. Another told us that she is the ‘Scrabble Queen’, and also enjoys other games like dominoes. Daily outings for walks or to purchase personal sundries, and visits to local coffee shops, etc, are also integrated into individual’s routines, often as part of a care plan to help residents with self confidence and responsibilities. One resident goes out to a day centre two or three times a week, which she really enjoys. She also maintains close contact with a local Rabbi who assists her to follow her faith as she wishes. She showed us pictures of a recent religious ceremony that she had participated in, and proudly gave us a resume of the presentation from the bible that she had presented at this celebration. In addition to individual activities, the residents also enjoy spending time relaxing in the home’s communal areas listening to music or watching television, and on occasions going out as a group to places such as garden centres. There are menus on display for a two- week period in the dining area of this home. Previously it had been suggested through an inspection, that picture menus might be beneficial. We saw a recent resident questionnaire, which included this suggestion. The results indicated that 100 of the residents would prefer to discuss the menus with the cook, and continue with the system they presently used. Therefore picture menus were not introduced. The menus identify a wide range of nutritious meals, and although daily alternatives are not scribed into the menu, the residents were very quick to tell us that they could always ask for an alternative. One resident told us that she does not eat pork products. She explained that she had seen a recipe for ‘hake’ on a television programme, and in consultation with the cook, she had this as an alternative. She also advised us that she has dietary requirements relating to her religion, and these are always considered and addressed. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18, People using the service experience good quality outcomes in this area. People living in Kirby House know who to speak to within the home if they have concerns, however information about who to contact outside the home is not always reviewed in a timely way. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: No complaints have been received either by Kirby House or by CQC since the last inspection one year ago. We did however see internal correspondence relating to the sofas being removed from the home, and advocacy support had been involved in addressing this matter. This was resolved and the sofas returned. The manager keeps a clear record of any concerns that have been raised, how they were managed and resolved. None of the residents that we spoke to had any concerns about their care provision, and they were aware of who they would approach in the home if they were not happy. There is a sheet instructing residents how to complain, on display in the hallway of this home, however some of the contact names/ details on this sheet were incorrect due to changes in the management structure of the Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 16 company. Therefore if for any reason residents were not comfortable approaching staff in the home, it is unlikely they would know what to do or who to contact. The manager amended these details the day after the inspection, so they are now correct. During this inspection we looked at the information documents for this service. We found that reviews that were requirements at the previous inspection had still not been addressed. For example there were contact details for NCSC at the Bedford office address. NCSC has not existed for some years now and the Bedford office closed in November 2007. It is important that people entering this home have the correct contact information. We spoke to the manager about this issue, and as previously explained; she told us that due to lack of administration support and limited office management hours, she does not have the time to address all these issues single-handed. This has resulted in non-compliance of requirements from the last inspection in June 2008, and must now be addressed as a priority to avoid CQC taking further action. The manager reacted quickly to our feedback and amended these documents the day after the inspection. It is essential this information is kept under review. The manager understands the principles and processes relating to safeguarding reporting, and the staff in this home have all undergone some training on this subject, and completed questionnaires to monitor their understanding and knowledge. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 People using the service experience adequate quality outcomes in this area. The home is generally clean, comfortable and well maintained however some areas of the home may not be suitably equipped for residents as their conditions deteriorate through the natural ageing process. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This is a small home, currently shared by five residents. It is generally well maintained, and provides a comfortable, safe home for them. However environmental improvements, as previously discussed, such as a level access shower, would enable some of the residents to be more independent. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 18 With the exception of one small area by the front door, where there is an unpleasant odour, the home is clean. However this unpleasant odour is outside the vacant room and needs to be addressed before a new resident moves in. There had previously been concerns raised, relating to the homes suitability for managing some individual’s disabilities, and natural deteriorations caused by the ageing process. This resulted in one resident being moved to a new placement, and an occupational therapist assessment and report being submitted to CQC. The departure of this resident has impacted on the well being of one other resident in particular, as they had been living together for many years and were like family. The report / improvement plan that we were shown indicates that a number of the ‘actions’, although assessed and given a cost figure, have not been completed, this includes some, which had been identified as high need, such as a portable powered bath lift / level access shower. The communal areas were generally comfortable, clean and tidy, with pictures and paintings in place on the walls. However we were told, by residents, that recently the comfortable sofas in the lounge area were removed and taken to another home, and were replaced with “horrible hard green chairs”. Only after the manager complained, and the advocacy service became involved, were these sofas returned. We are unsure why this should have happened, but believe it was inappropriate and left residents feeling ‘second best’. One of the bedrooms in this home has en suite facilities, and there are two communal bathrooms. The manager told us that there had been an agreement for a wet room to be installed however this has not yet happened. The bedrooms that we visited were decorated and furnished with personal photographs and ornaments that reflected the individual’s life history. A previous inspection had identified the need for clearer signage throughout the home, however consultation with the residents, indicated that they do not feel this is necessary as it is only a small home and everyone is very familiar with the layout and who lives in which room. This is the residents’ choice in their home. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience good quality outcomes in this area. People in this home have confidence in the staff that care for them, they know the staff well and can communicate with them freely. Accurate job descriptions clearly define the roles and responsibilities of staff. The recruitment process in robust and the manager is aware of any gaps in training, which need to be addressed. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is a small team of staff in this home. It consists of Mental Health Nurses and care assistants, some of whom have worked in Kirby House for many years. There is also a cook, a cleaner and a maintenance man permanently employed. However on the day of the inspection both the cook and cleaner were off sick, therefore an extra member of care staff was booked on duty. We were however a little concerned that the manager for this home does not have any administration support, and is only allocated six hours for office work Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 20 each week. We feel this is insufficient and have addressed this in more detail in the management section of this report. This concern was raised at the two inspections prior to this however this has still not been addressed adequately. During this inspection we looked at the files of three staff. One qualified nurse, one carer and the housekeeper. All the relevant recruitment documentation was present in these files including; fully completed application forms, Criminal Record Bureau (CRB) and POVA first checks, Nursing and Midwifery Council (NMC) verification where necessary, various forms of identification including photographs, references from appropriate sources, health questionnaires, interview records and contracts/ terms and conditions of employment. Some documents did however have missing dates and signatures. The files that we looked at indicated that the staff attend mandatory training and refresher courses in a timely way, and we saw evidence to suggest other courses such as continence management and challenging behaviour are also available for staff. During this inspection, we spoke with some of the staff on duty, and also observed some of the care interactions during the morning. The staff were respectful in their approach to residents, and interactions were spontaneous, relaxed and appropriate. Staff were confident in their roles and worked as a team to ensure that everyone’s needs were fully met, whether they were social or physical. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38 People using the service experience good quality outcomes in this area. The manager has the required qualifications and experience and is competent to run this home. She has a clear understanding of the key principles and values of the home, and the residents are central to shaping the delivery of service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager in this home is a Registered Mental Health Nurse. She has an NVQ 4 in care and has also completed her Registered Managers Award. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 22 She is knowledgeable and sensitive to the needs of the residents who live in Kirby House. She is supported by a small team of qualified nurses and care staff who portray a strong commitment to the home. Many have worked in Kirby House for a long time and know the residents very well. The residents consider them family. The home is run with the residents best interests as the central focus. Their wishes and needs are undoubtedly a priority in this home. Any changes in the home that may affect the residents, are always addressed through consultation with them. Residents’ questionnaires that we looked at demonstrated how over recent months topics such as menus, frequency of residents meetings, cleanliness of the home and social activities have been actively discussed. This home only manages money for one person who lives here. We looked at the account documents for this individual, and checked that funds remaining balance accurately. All transactions were clearly recorded and signed by the resident herself and a member of staff. All the records that we looked at relating to residents care, and health and safety in the home, were accurately completed. Risk assessments were in place and being kept under review, and the maintenance man carries out all fire, environment, water and emergency lighting checks, which are all clearly recorded. Accidents and incidents in the home are clearly recorded both in individuals’ daily records, and on appropriate reporting sheets. Regulation 37 notifications are submitted appropriately, and the manager is aware of when the safeguarding team need to be involved. We looked at staff supervision records. Although there is a system in place, supervision is rather sporadic. The manager advised us that this is something that she knows she needs to address, however she currently only has six hours a week allocated to management/office duties, the rest of her time is spent working ‘hands on’ with the residents, and she does not receive any administration support. Therefore she has to prioritise duties for this time, and some areas are consequently not receiving the attention they require. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 23 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 2 3 3 3 3 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 2 17 X 18 3 3 3 2 2 3 3 2 2 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 3 3 3 X 3 2 3 3 Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4 Requirement The information within the statement of purpose including contact details to make a complaint must be kept up to date. This is to ensure that people have access to accurate information. Due to further changes in the management structure of the home and CQC information, an extended timescale has been applied to this requirement. Previous timescale 30/09/08 People who live in this home must be cared for by staff that are appropriately supervised. Timescale for action 30/06/09 2. OP36 18(2) 31/07/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 25 1 OP22 The company should continue to consider the environment to ensure it enhances the independence of the people who live there. Kirby House Mental Nursing Home DS0000017677.V375424.R01.S.doc Version 5.2 Page 26 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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