Care Home: Kirkby Manor Care Home

What the care home does well Staff told us that assessments included communication, moving and handling, sleep patterns, personal care wishes, diet and nutrition. Staff told us that they were working towards achieving a personalised needs assessment for every one. Care plans were being evaluated and reviewed supervised by the project managers to ensure that people’s diverse needs are identified before they move into the home. What has improved since the last inspection? Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.2 The initial assessments have been improved and are dated and signed now. People’s cultural needs have been addressed through the activities and diet provided. A record of all complaints received at the home is now available. A quality assurance procedure and information supplied by relatives and the people at the home is now in place and is available at inspections. The lift has been repaired and is now in full working order. A re-assessment of the staffing levels to better match the diverse needs of the people at the home has been achieved by the provider. What the care home could do better: When instructions in care plans are not clear they will fail to give sufficient information for staff to follow it will result in loss of continuity of care that anyone can follow. A number of people’s rooms still have an unpleasant odour. This spoils their enjoyment of the home and should be corrected without further delays. Key inspection report CARE HOMES FOR OLDER PEOPLE Kirkby Manor Care Home Beech Avenue Kirkby In Ashfield Nottinghamshire NG17 8BP Lead Inspector Lesley Allison-White Key Unannounced Inspection 3rd August 2009 1:30 DS0000063843.V378513.R01.S.do c Version 5.3 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. Kirkby Manor Care Home DS0000063843.V378513.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 Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirkby Manor Care Home Address Beech Avenue Kirkby In Ashfield Nottinghamshire NG17 8BP 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) 01623 723724 01623 753931 kirkby@hallmarkhealthcare.co.uk www.hallmarkhealthcare.co.uk Hallmark Healthcare (Kirby in Ashfield) Ltd Manager post vacant Care Home 40 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (40) of places Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users shall be within category DE/E Date of last inspection 28th October 2008 Brief Description of the Service: Kirkby Manor is a modern, purpose-built 40-bedded care home offering specialist care for older people with mental illness. Qualified nursing care is provided at all times. The home is located in a cul-de-sac in a residential area of Kirkby in Ashfield. The town centre is approximately half a mile away. The accommodation is on two floors with a passenger lift to assist independent access. All of the bedrooms of all single occupancy. There is a safe enclosed garden, which is easily accessible by residents. 2009 fees for the service range from £419 - £700 per week depending on dependency needs. There are additional charges for hairdressing and chiropody. Further information about the home is available in the brochure and service user guide or from the website: www.hallmarkhealthcare.co.uk. The manager welcomes any telephone enquiries and a copy of the latest inspection report is available in the entrance foyer. Kirkby Manor Care Home DS0000063843.V378513.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 1 star. This means the people who use this service experience adequate quality outcomes. The focus of inspections undertaken by the Care Quality Commission is upon outcomes for people and their views of the service provided. This process considers the service’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. This was a key unannounced inspection that took place on a week day. It lasted seven hours. As part of the preparation for this visit we looked at all the information that we have received, or asked for, since the last key inspection on the 4th July 2007. This included: The annual quality assurance assessment (AQAA). This is a selfassessment that focuses on how well outcomes are being met for people using the service. What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement and the previous key inspection report. During the site visit ‘case tracking’ was included as part of the methodology. This involved looking at the records of three people’s files representing a cross section of the care needs of individuals within the home. We observed people living in the home many have dementia or other problems that affect their communication. Discussions were held with different individuals as able, and observations were made of the interactions between the staff and the people who live in this service. Individuals care planning and associated care records were also examined and some private and communal facilities inspected. Discussions were also held with staff about the arrangements for care provided and also for staffs’ recruitment, induction, deployment, training and supervision. What the service does well: Staff told us that assessments included communication, moving and handling, sleep patterns, personal care wishes, diet and nutrition. Staff told us that they were working towards achieving a personalised needs assessment for every one. Care plans were being evaluated and reviewed supervised by the project managers to ensure that people’s diverse needs are identified before they move into the home. What has improved since the last inspection? Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.2 Page 6 The initial assessments have been improved and are dated and signed now. People’s cultural needs have been addressed through the activities and diet provided. A record of all complaints received at the home is now available. A quality assurance procedure and information supplied by relatives and the people at the home is now in place and is available at inspections. The lift has been repaired and is now in full working order. A re-assessment of the staffing levels to better match the diverse needs of the people at the home has been achieved by the provider. 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. Kirkby Manor Care Home DS0000063843.V378513.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 Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service have information about the home in order to make an informed decision about whether the service is right for them. EVIDENCE: A copy of the Service User Guide and Statement of Purpose is available to all new people and their family members. (This is information about the service.) A copy of the last inspection report is available from the office. We looked at the care plans of people with different needs and three relatives spoke with the inspector. We saw that assessments are completed prior to admission at the home. We saw that older assessments show that they were not always dated and signed Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 9 as required however newer assessments indicated that this area of concern had improved. Records included assessment information completed by social services and / or hospital staff, and a pre-admission assessment by the home. Further assessments had been completed when the person came to live in the home. Assessment information had been reviewed monthly. Staff said that they have guidelines that they can follow as a base line for care to be provided. Staff told us that assessments included communication, moving and handling, sleep patterns, personal care wishes, diet and nutrition. Staff told us that they are working towards achieving a personalised needs assessment for every one, many of the assessments and care plans were being evaluated and reviewed supervised by the project managers. This ensures that people’s diverse needs are identified before they move into the home. Two of the people who were observed were unable to explain their admission process due to their mental states. The third person said that they were involved in the admission process and documents relating to their care planning was dated and signed by them or their relative. Intermediate care is not offered at the home. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care is not always based on individual’s needs and as a result some people may feel that their dignity is not always respected. EVIDENCE: We saw that each of the care plans included details about the care given and risk assessments were in place for trips and falls, nutrition, moving and handling. Sometimes however, important information was not included. An example of this was: ‘X has been admitted to hospital for Type X diabetes due to high blood sugar levels in the past’. ‘Staff must monitor blood sugar levels to ensure that they remain within the normal range’. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 11 Missing from this was information about the normal range for X. If had it been included it would make it easier for staff to recognise when X’s blood sugar levels are not normal and they would be able to respond to X before X became ill. We saw a care plan that said staff should: ‘Ensure that the insulin site is rotated’ this was not recorded on the sheets seen. Another instruction to staff was to: ‘Offer complex carbohydrates rather than simple carbohydrates’ examples of both types were not stated for staff to recognise what these are as they may forget or be unfamiliar with them. Another care plan stated that a hoist was to be used however, the person could walk with the assistance of a walking aid and needed help to get up to walk. We saw that a lifting belt was used by the staff to raise the person to an upright position. Staff agreed that the care plan could be misleading for them to follow and result in a loss of independence for that person. However, staff also felt that they knew people at the home in sufficient detail to prevent this from happening. When instructions in care plans are not clear or give insufficient information for staff to follow it will result in a lack of continuity of care. However, we observed staff moving a couple of people and they appeared to move them safely from an arm chair to a wheelchair. We saw care plans with evidence of follow-up to treatments and visits by other health care professionals such as specialist nurses, the chiropodist or for hospital appointments. This means that people at the home receive follow-up care and treatments when they need it. We saw accident reports completed for falls and care plans were evaluated. In August 2008 we completed an Annual Service Review (ASR) and from comments received in the surveys we decided to undertake a Random Inspection in October 2008 to review staffing levels and the impact on care provided for people at the home. Please see staffing and management within this report. People who spoke with the inspector said that they felt their care needs were being met and that they were treated with respect and dignity. However in a complaint received this year by the inspector someone from the home said that they did not feel that their needs were being met as ‘they were being dressed for bed before 9pm and did not like this, the bedroom had a bad smell and the commode was not checked after use.’ The issues of the complaint were resolved and actions put into place to change this pattern of behaviour by staff. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 12 A Safeguarding strategy meeting was held in June 2009 due to poor record keeping by staff, discrepancies in charts and staff not responding in an appropriate way. The outcome of meeting was for Kirkby Manor to improve staffing levels, to have better communication between staff and with relatives and for house smells to be improved and eliminated. Three people were to have one to one funding for their assessed needs. We saw improvements taking place in all the areas mentioned. Comments from families included: ‘Our relative receives help with washing from two staff and is offered a strip wash or shower’. ‘Our relative is dressed in their clothes as appropriate for the weather conditions.’ ‘If our relative is poorly at night the staff will call a doctor and contact us as next of kin’. ‘We are happy with the care provided as our relative came from a unit for challenging behaviour and seems more settled now. We feel that our relative is well looked after, eats their meals and has put on weight since being here’. ‘Our relative seems more settled now and I take them out on nice weather days in the garden’. ‘On days when our relative is not so well staff will help them. Staff will encourage them to help themselves as much as possible’. For any problems we would expect staff to ring us.’ The Annual Quality Assessment sent in by the provider tells us: ‘At Kirkby Manor we use the Boots monitored dosage system for the drug administration and we adhere to the Hallmark Healthcare medication policy and procedures. This covers the safe administration, use and storage of all medication including controlled drugs’. The medications of four people were checked and the controlled drugs of a further two people were checked and found to be satisfactory. People receive their medicines in a safe manner. At Kirkby Manor there is a diversity of people with various conditions and levels of ability who are assisted by staff of both sexes who continually attempt to meet their needs. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 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): Standards 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assisted to exercise choices and control over their lives and are provided with pleasant surroundings to enjoy their meals. EVIDENCE: An activities coordinator is provided to ensure that people are offered an activity each day to take part in. People who live at the home who were able to comment on this said ‘I will play bingo with others sometimes.’ We observed seven people in the lounge upstairs listening and watching an old time film show. Two other people were seen in a smaller lounge they did not appear to have any activity provided except for a television that neither of them appeared to be able to watch however at drink time intervals, staff were seen interacting with them. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 14 In the care records of one of the people with dementia we saw that they were included in activities at the home. Activities their care records included, being invited to the weekly activity entertainment. The annual assessment (AQAA) completed by the provider tells us: ‘We have an activities co-ordinator who plans and implements activities for the residents either in group or, individual settings. There is also an in-house newsletter to keep residents informed of new events. The activity co-ordinator uses the information from the care plans to plan the individual activities and encourages the care staff to continue with this. Activities are displayed on both floors and the activities co-ordinator is building on links with the local community.’ Families who spoke with the inspector were aware of the coordinator and said that: ‘She seems to do a good job.’ On meals the AQAA tells us: ‘The menu at Kirkby Manor is nutritious and well-balanced as evidenced by the recent nutrition audit with Nottinghamshire County Council. Residents are always offered two choices and the menus are displayed on both floors. The food is adapted and served to meet all nutrition requirements.’ We observed a meal time. Staff tried very hard to offer people choices with the meals ensuring that something nutritious is offered within the choices. Two staff members explained that they will also include a food supplement with the meal or after the meal where people have been prescribed this by the doctor and have a poor appetite and weight loss. They explained that this would be part of the person’s plan of care that they follow. We observed staff assisting people with their meals they appeared unrushed even though they were busy. When some staff members were observed taking shortcuts the project managers who were also observing the meal time corrected this practice in an appropriate way. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 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): Standard 16 and 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s rights have not always been fully supported by the staff, this has meant that some people did not feel involved or protected. EVIDENCE: There is a complaints policy and procedure in place and it is displayed within the home and found again within the Service User’s Guide. However the contact details for CQC should be updated to reflect the new address as being the contact centre in Newcastle upon Tyne. The Care Quality Commission (CQC) has received information about the service that has caused concern. The issues raised have been dealt with in a satisfactory manner. This includes safeguarding referrals (Adult protection issues). Staff spoke with the inspector. They said that they would take any concerns about care issues to the project managers. Staff said they were aware of safeguarding issues and had received training for this. They said that they knew how to use the ‘whistle blowing policy procedure’ to alert external agencies such as the Police, Social services or CQC should a situation that Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 16 affects a person living at the care home be unresolved by the providers. In this way people at the care home are protected from harm. Comments from visitors include ‘I would go to the project managers if we had a complaint and we believe it would be dealt with.’ Comments from people at the home included: ‘My family would complain for me.’ ‘I would talk with my relative then I would complain’. ‘I would go to the office or speak to one of the carers; my key worker is very nice’. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 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): Standard 19 and 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service provides a homely environment and has a rolling programme to improve the fixtures but occasionally there is some slippage. This can lead to people not feeling that their needs are not fully met. EVIDENCE: The AQAA tell us that: ‘A refurbishment has taken place on both floors and this is almost complete. The new flooring is more suitable for the client group and cleanliness has improved. Domestic hours have been increased to allow for extra cleaning. The garden area is being worked on and is more suitable for the client group’. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 18 We saw that domestic staff attempted to keep the home clean and free from smells however there are still some rooms that smell. The project managers explained that the process of replacing flooring for more suitable materials has already started and will continue until all room smells have been resolved. We saw three bedrooms and three public areas. In some bedrooms the issue of unpleasant odours still exists. In the public areas that we saw they were kept clean and tidy. Relatives told us that they have noticed ‘room smells’ but have been told that a new carpet and thorough cleaning will take place soon. Visitors also mentioned that when floods accidentally take place people in the rooms are not always moved to another room and this concerns them. This was discussed with the project managers who said that they would ensure that wherever this has happened people can be moved. This will take place to ensure that everyone is kept comfortable at all times. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 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): Standard 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are clear about their roles and what is expected of them. People at the home feel that staff responds to their needs. The registered provider has recruitment procedures that are fully implemented so that people can feel protected in this way. EVIDENCE: The staff rotas showed that the usual staffing levels were seven care assistants down stairs and three care assistance upstairs of the home and two Registered Nurses during the morning and afternoon shifts. Three of the care assistants during each day was used provide agreed one to-one support for three people living in the home. There were three care assistants with one Registered Nurse for the night shift. The AQAA tells us: ‘The staffing levels are appropriate to the needs of the residents with 1-1 supervision for three residents with a high level of need. The skill mix is also planned to maintain standards of care and ensure there are Registered Nurses and senior care staff on every shift. The level of NVQ attainment is at 79 including level 2 and 3. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 20 The staff are trained to a high standard and training is actively encouraged and proactive. We have an in house trainer and also an electronic training system that staff can access on-site. All staff completes the Common induction standards and there is a rolling training programme and training is identified on the training matrix. The El-Box system has records of all staff training and in what subjects.’ We saw that the training matrix illustrates the staff that have completed training and on what date with each staff member having an individual training folder. However staff told us that: ‘They need to be supported and encouraged to use the El-box system on-site or to access the system at home more. It can be difficult to do after a days work.’ The AQAA supports the staffs concerns and has identified this need as it states: ‘We need to always ensure that staff are free to access the in-house training’. We saw records that show that the electronic system (el-box) has been updated and improved and includes the Protection of Vulnerable Adults, Infection Control, Substance training known as COSHH and up-dated fire training. As part of a review of the staffing and following the safeguarding alerts the Annual Quality Assessment completed by the provider tells us: ‘We have been proactive in negotiating for closer supervision for the residents with a high level of need.’ When cover for sickness and holidays is required this is provided by permanent and bank staff. Agency staff are used to ensure the one-to-one provision is maintained. A Random inspection took place in October 2008 to look at the staffing and management of the home following comments on surveys received from people living in the home and their relatives, and from the outcome of the Annual Service Review carried out in August 2008. There were concerns about not having sufficient staff to meet peoples’ assessed needs. Meal times were not well managed and we observed that more help was needed to manage this better. Since this report people have had their needs reassessed and further funding is provided to meet people’s assessed needs with three people now having one to one supervision. We saw staff records that contained evidence of good recruitment practices and had the relevant information in them. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 21 A key worker system is in place. Staff told us that the key worker provides contact with the family and will ensure that daily needs such as toiletry is provided by the families. Staff told us that they have received sufficient training and in this way they felt able to support and protect the people who they care for. Both project managers are actively involved in the day to day supervision of staff at the care home. This is having a positive impact on the care of people who work and live at the home. Visitors also said that they felt there was a ‘good improvement.’ Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 22 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): Standards 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health, safety and welfare of the people at the home is protected and promoted. EVIDENCE: In a previous random report we looked at the management of the care home to ensure that people were safe. The acting manager had been in post since July 2008. She said she was in the process of completing the necessary paperwork to register with CSCI now known as the Care Quality Commission. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 23 The acting manager explained that there were problems and gave details of the action she was taking in response to concerns about staff turnover and sickness. Staff told us that staff turnover had decreased and that new staff had been recruited. Staff said that the staffing situation had improved since the acting manager had been in post. However since that report the acting manager who became the Registered Manager has left her post and two project managers are in place to manage the home on a daily basis. The AQAA tells us that: ‘management encourages communication with relatives and has an open surgery every week’. Regular meetings take place with all staff and residents. The management team has built up a rapport with outside agencies and is involved in reviews and audits. There are policy and procedure manuals on all floors and the manager ensures that staff knows and understands these. The manager plans and implements regular Health and Safety meetings to maintain safe systems of work. We saw the quality audit questionnaire feedback and that actions from it were being undertaken. The NHS Quality Monitoring Officer visited twice in June 2009 and found that ‘a lack of effective leadership and management had occurred in the past year. This has had a significant impact on the functioning of the home and the professionalism of staff. Standards of cleanliness had not been maintained, systems to support effective team communications and day to day planning and coordination of care delivery were not in place. Staff morale and team working had been affected’. However, on the second visit they found that: ‘The management team appear to be implementing actions on a daily basis and ongoing improvement was evident’. At this inspection staff said that they ‘felt more settled now’ and had a good attitude to work. People at the home who were able to comment said that they were happy. Relatives’ comments were also positive about the way forward. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 24 The project managers confirmed that Health and Safety needs at the home was met and that all the staff had fire training to ensure that people at the home are kept safe from the risks of fire. The project managers also said that water safety is maintained and radiators do not pose a risk of injury to the people at the home as they are protected by safety covers. At the random inspection in October 2008 the smells within the home was highlighted. In the environment section of this report relatives commented about the smell of some of the bedrooms. The project managers acknowledged that this issue should not be allowed to continue indefinitely as it was having an impact on the well being of different individuals at the home. We saw that peoples’ money is stored and managed safely. People have access to it when they want it with some people keeping their money with them. Each room has a lockable facility in it for the safety of people’s valuables. A copy of the Care Quality Commission registration certificate was displayed and a copy of the Employer’s Liability insurance was seen. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 25 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 Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 26 CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 27 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 OP7 Regulation 15(1) Requirement Care plans must clearly describe how resident needs are to be met and where a need is identified a care plan must be written for this. This will ensure that staff know how to meet residents’ needs. We set this before on 28/10/08 and it has not been completely met. Action must be taken to eliminate all offensive odours to ensure a safe, clean and pleasant environment for people living in the home. We set this before on 28/10/08 and it has not been completely met. Timescale for action 28/10/09 2. OP19 13(3) 31/12/09 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 Good Practice Recommendations DS0000063843.V378513.R01.S.doc Version 5.3 Page 28 Kirkby Manor Care Home 1 Standard OP22 The contact details for CQC should be updated to reflect the new address as being the contact centre in Newcastle upon Tyne. Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@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. Kirkby Manor Care Home DS0000063843.V378513.R01.S.doc Version 5.3 Page 29 Copyright © (2009) Care Quality Commission (CQC). 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