Care Home: Kirkstall Lodge

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What the care home does well The individual aspirations and needs of prospective residents are assessed during a resettlement process that provides an opportunity for the person to visit and ‘test drive’ the home before making a decision to move in. There is good information about each persons care needs and goals and this written information is reviewed regularly. This ensures that the written plans are amended when and if a persons needs change. Residents are given the assistance they need to make decisions and emphasis is placed on communication. Risks are identified and management plans put in place as necessary.Kirkstall LodgeDS0000053104.V374931.R01.S.docVersion 5.2Residents are supported to maintain and develop a fulfilling quality of life. There are opportunities for personal development and leisure and staff help residents to maintain and develop friendships and relationships. There are healthy meals that meet the cultural and nutritional needs of each resident. Staff comments include:“The service plans well for different kinds of activities for the service users and supports them to fully socialise and make good use of social amenities” Another member of staff feels that ‘in house training’ is an area that the service does well in. Residents receive appropriate support to maintain their personal care and their physical and emotional needs are met. Residents are protected by the homes policy and procedures in regards to the administration of medicines. There are opportunities for residents to make complaints and raise concerns and when they do they are listened to and taken seriously. Residents are protected from abuse and staff know what to do in situations where they might suspect abuse. The home is comfortable and clean. Bedrooms are well furnished and personalised. Steps are taken to ensure environmental safety. What has improved since the last inspection? Quality assurance systems have been introduced. Areas of the home have been re-decorated. The back garden is better and residents are involved in the gardening and choosing plants. There is better focus on making information accessible to residents who would find a text only document difficult to understand. More staff have attained a vocational qualification in care or are working towards one. What the care home could do better: There is an accessible guide to the services that the home provides, although here is insufficient information about fees and what they are used for.Kirkstall LodgeDS0000053104.V374931.R01.S.docVersion 5.2The need for a keypad-locked front door must be looked at carefully as residents are being deprived of their liberty and their freedom to leave the house. The placing authority must be notified of the restrictions in place for one resident who is too unsteady on her feet to use the rear garden fire escape route in an emergency. This must be done to ensure that there is consideration of her overall safety in the home and suitability of the physical environment to meet this persons needs. There has been inconsistent management in the last year and this has reduced the overall training and development planning for the team and the home. Staff should be supervised and appraised regularly. Key inspection report CARE HOME ADULTS 18-65 Kirkstall Lodge 56 Kirkstall Road Streatham London SW2 4HF Lead Inspector Sonia McKay Unannounced Inspection 22nd April 2009 09:30 Kirkstall Lodge DS0000053104.V374931.R01.S.doc 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 home adults 18-65 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. Kirkstall Lodge DS0000053104.V374931.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 Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirkstall Lodge Address 56 Kirkstall Road Streatham London SW2 4HF 020 8678 8296 020 8678 8296 kirkstall@caretech-uk.com 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) Kirkstall Lodge Limited Manager post vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 6 2nd June 2008 Date of last inspection Brief Description of the Service: Kirkstall Lodge is a care home for six adults with a learning disability. The semi-detached house is located in a residential street in Streatham, South West London. It is close to public transport routes, shops and leisure facilities. The home is unsuitable for people with restricted mobility as front access is via a number of steps. There is a small rear garden with an outbuilding that is used as an office. The home is owned and managed by Beacon Care Group Ltd, a private care provider with many other homes in London and the South East of England. On the 29th April 2008, Beacon Care Group homes, including Kirkstall Lodge Ltd, were acquired by Caretech Community Services Ltd, another large national care provider with homes across the country. Prospective residents are given a copy of the Service Users guide that gives information about the home and the services provided. A copy of the most recent Commission inspection report is available in the reception area of the home. Fees range from £816.06 to £1,634.78 per week and vary depending on the individual care needs of each resident. The core costs of a placement at Kirkstall Lodge Ltd is £979.17. Kirkstall Lodge DS0000053104.V374931.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. Whilst this service remains rated as Adequate there is improvement. This inspection was carried out over one day. The methods used to assess the quality of service being provided were: • • • • • • • • • • Talking with the newly appointed home manager and staff on duty Looking at the ‘Annual Quality Assurance Audit’ completed by the deputy home manager (this document is sometimes called an ‘AQAA’ and it provides the Commission with information about the service) A resident guided tour of the communal areas of the home and some of the bedrooms Sending surveys to the residents and staff before the inspection Surveys were completed by six members of staff and key staff completed surveys on behalf of all six residents, who need assistance with written communications Looking at records about the care provided to two of the residents Talking with residents Looking at records relating to recent staff recruitment and training Looking at the way medicines are handled by staff in the home Looking at issues that the Commission has been notified about since the last inspection and how they were handled The Commission would like to thank all who kindly contributed their time, views and experiences to the inspection process. What the service does well: The individual aspirations and needs of prospective residents are assessed during a resettlement process that provides an opportunity for the person to visit and ‘test drive’ the home before making a decision to move in. There is good information about each persons care needs and goals and this written information is reviewed regularly. This ensures that the written plans are amended when and if a persons needs change. Residents are given the assistance they need to make decisions and emphasis is placed on communication. Risks are identified and management plans put in place as necessary. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 6 Residents are supported to maintain and develop a fulfilling quality of life. There are opportunities for personal development and leisure and staff help residents to maintain and develop friendships and relationships. There are healthy meals that meet the cultural and nutritional needs of each resident. Staff comments include:“The service plans well for different kinds of activities for the service users and supports them to fully socialise and make good use of social amenities” Another member of staff feels that ‘in house training’ is an area that the service does well in. Residents receive appropriate support to maintain their personal care and their physical and emotional needs are met. Residents are protected by the homes policy and procedures in regards to the administration of medicines. There are opportunities for residents to make complaints and raise concerns and when they do they are listened to and taken seriously. Residents are protected from abuse and staff know what to do in situations where they might suspect abuse. The home is comfortable and clean. Bedrooms are well furnished and personalised. Steps are taken to ensure environmental safety. What has improved since the last inspection? What they could do better: There is an accessible guide to the services that the home provides, although here is insufficient information about fees and what they are used for. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 7 The need for a keypad-locked front door must be looked at carefully as residents are being deprived of their liberty and their freedom to leave the house. The placing authority must be notified of the restrictions in place for one resident who is too unsteady on her feet to use the rear garden fire escape route in an emergency. This must be done to ensure that there is consideration of her overall safety in the home and suitability of the physical environment to meet this persons needs. There has been inconsistent management in the last year and this has reduced the overall training and development planning for the team and the home. Staff should be supervised and appraised regularly. 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. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard 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. 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. There is an accessible guide to the services that the home provides, although here is insufficient information about fees and what they are used for. The individual aspirations and needs of prospective residents are assessed during a resettlement process that provides an opportunity for the person to visit and ‘test drive’ the home before making a decision to move in. EVIDENCE: The statement of purpose must be revised to include information about recent changes in home management. The document contains information about the registered provider, staff in the home and how the service is run. There is also a guide for people using the service. This contains a summary of the ‘statement of purpose’ and a description of the services provided. The guide is user friendly and contains many colour pictures, making it more accessible to people who would find a text only document difficult. During the previous inspection a requirement was issued as Regulations about the service user’s guide have been amended to require greater detail to be included about the standard package of services provided in the care home, Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 10 the terms and conditions which apply to key services, fee levels and payment arrangements. The guide is also required to state whether the terms and conditions (including fees) would be different in circumstances where a person’s care is funded, in whole or in part, by someone other than the person. Any notice of an increase of fees is to be accompanied by a statement of the reasons for such an increase. Discussion with the homes quality and performance manager indicates that the updated guides are at draft stage and have yet to be finalized and issued. The requirement is therefore not met and is repeated in this report. (See requirement 1) No new residents have moved into the home since the last inspection visit and the home has no vacancies at this time. Assessment at previous inspection indicates that’s peoples needs are assessed before they are offered a placement in the home. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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): 6, 7 & 9. 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. There is good information about each persons care needs and goals and this written information is reviewed regularly. This ensures that the written plans are amended when and if a persons needs change. Residents are given the assistance they need to make decisions and emphasis is placed on communication. Risks are identified and management plans put in place as necessary. EVIDENCE: Records relating to the care of two of the six residents were examined. Each resident has a comprehensive set of assessment documents providing detailed information about care needs, risks and planned care and support. All care plans and risk assessments have been reviewed recently and placing authorities have recently conducted statutory placement reviews for all six residents living in the home. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 12 Residents who are able have, in some cases, also added their comments to each element of the care plan and goal setting. This is good practice. There is a form for staff to sign to confirm that they have read and understood care information contained in the files. This is good practice, although the files are rather large, and although there is good information available it is not easily accessible, making it difficult for new staff to access comprehensive accounts of current care needs and risks. Review of how this information is kept was recommended at the last inspection. During this inspection I was advised that a new care planning system is being introduced and the files will be reorganised when the new plans are in place. A risk audit tool is in place. This lists areas of risk to be considered for each person. If a particular activity or situation presents a hazard to a resident a more detailed risk assessment is developed to include action that staff should take to reduce the danger. The managers of the home demonstrate an understanding of the need for people to take risks as part of developing their independent living skills and lifestyles. Residents have a learning disability and need support with communication and decision-making. There is progress in training staff to recognise and use signed communication and to develop a range of pictures and photographs to assist in communicating information about choices and plans. Each resident has a key-worker from within the team who meets with them regularly, makes appointments, updates records and plans and monitors progress in achieving specific goals. There are reports of key-working activity available and these include records of discussion and meetings with residents. Relatives and advocates are also involved in some cases and multidisciplinary meetings in the best interest of individual residents are called when major decisions are to be made, for example health treatment under any form of sedation. There are monthly ‘house’ meetings where residents can discuss issues as a group and make decisions with staff. These meetings are held regularly and are used to decide on issues such as group outings. Residents require support to manage their finances. In some cases they need full support and the registered provider is the state benefit appointee. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12, 13, 15, 16 & 17. 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. Residents are supported to maintain and develop a fulfilling quality of life. There are opportunities for personal development and leisure and staff help residents to maintain and develop friendships and relationships. There are healthy meals that meet the cultural and nutritional needs of each resident. Consideration should be given to the implications of having a locked front door. EVIDENCE: Residents are involved in a variety of daytime activities; these include attending day centres, college courses, therapeutic employment and activities with staff. There is also support for residents to engage in evening activities such as visits to the pub, cinema and restaurants. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 14 There is a house vehicle and driver. There are outings to places of interest and group or individual holidays. Residents maintain their friendships and relationships whilst living in the home, with visits, telephone calls and letters. One resident told me that he liked a recent trip to see Buckingham palace and he showed me some pictures. He said “I went with my friend”. He was referring to the member of staff that supported him for the outing. There is a television and music centre in the communal lounge and arts and crafts materials are available. One resident is supported to attend a mosque on a regular basis and there is good contact with his family. A range of culturally appropriate meals are prepared and served. The daily routines in the home are structured so that residents are woken in adequate time to prepare for their days activities. Residents were observed to move freely around the building, choosing whether to sit in a communal area or in their own bedrooms. Residents are also encouraged to get involved with cooking and laundry tasks. One resident was helping with the house cleaning and another was helping with the shopping. Residents are provided with a key to their bedroom door locks if they are able and wish to use it. The front door has a keypad type lock and residents, who cannot remember the code, are no longer able to open the front door. During a previous inspection staff said that the lock has been fitted to prevent one resident from leaving the home without staff knowledge and all residents need staff support to stay safe whilst out in the community. Meals are served in the dining area of the communal lounge. Records indicate that a range of meals are served in accordance with individual needs, such as wheat free, dairy free and culturally appropriate meal choices. Individual likes and dislikes are also recorded. Food is stored appropriately and fresh fruit and vegetables are available. Meals taken away from the home, for example, meals taken at a daycentre are paid for by the home, not by the resident. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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): 18, 19 & 20. 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. Residents receive appropriate support to maintain their personal care and their physical and emotional needs are met. Records relating to exercise programmes should be better kept as there are significant gaps. Residents are protected by the homes policy and procedures in regards to the administration of medicines. EVIDENCE: Residents require varying levels of support with maintaining their personal hygiene from full support to verbal prompting. Personal support is provided in private, either in bedrooms or in bathrooms and each person has a written personal care guideline detailing the nature of support required and the preferred routine. There are currently three male residents and three female residents. There are both male and female staff available to provide personal care. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 16 There is a designated key worker system in place and on occasions when additional staff are required they are supplied via a bank system from another home run by the registered provider. There is evidence that appropriate advice is taken in regard to specialist support from physiotherapists, occupational therapists and speech therapists and a number of adaptations and equipment are in place. Advice from dieticians and speech and language therapist is in place, and there is evidence that this advice is incorporated into plans and systems in the home. For example, there are gluten and dairy free produce available for a resident who is on a special diet and guidelines for how the food is to be prepared. There is evidence in records that the healthcare needs are well met and healthcare records are organised so that there is a clear record of healthcare needs and the outcome of any healthcare appointments. Since the last inspection individual health action plans have been developed with each person, as recommended in the previous inspection report. These plans have been developed with the input of relevant health professionals including the GP. Health recordings differ between residents and pertain to their individual health needs. Recordings for one resident include sleep charts, bowel movement charts and records of ankle exercises assisted by staff. The record for the daily ankle exercises is incomplete, with only a few recordings for February and March entered. Staff on duty said that they do the exercises with the resident each day. The records should be better kept to ensure that the required exercises are done regularly. Each resident has had a medication review in the last year. None of the current residents are managing their own medication and all need support from staff. All staff administering medicines receive training. Certificates are available in staff training records. Medication is stored in a locked steel cabinet in the staff office. A measured dose system is in place and new stocks are collected from the supplying pharmacist along with pre-printed medication administration records. Records examined have no gaps and are completed accurately. The use of external products (such as creams) is recorded. There is a sample list of staff signatures so that the person who administered a medication and signed the record can be identified easily. There is good information about the medications in use and the side effects they might have. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 17 There is a stock of home remedies in place, should they be required. There is also advice from each person’s GP as to what home remedies (medicines that can be purchased without a prescription) each person can safely used. There are no controlled drugs in use. There is no suitable controlled drugs storage available should any be prescribed. All residents are taking their prescribed medicines regularly and no prescribed medication is out of stock at the time of this inspection. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are opportunities for residents to make complaints and raise concerns and when they do they are listened to and taken seriously. Residents are protected from abuse and staff know what to do in situations where they might suspect abuse. The need for a keypad-locked front door must be looked at carefully as residents are being deprived of their liberty and their freedom to leave the house. EVIDENCE: There is an accessible complaints policy and procedures for how complaints are to be handled. There is a record of the complaints made and how they were resolved. There are regular house meetings for residents to raise issues and there are plans to start using a complaints and complements form during the regular one to one meetings that key workers have with each of the residents. Family and friends are to be invited to more social activities in the home as a way of encouraging their input and feedback about the way the home is running. Most staff have received training in the safeguarding procedures for protecting vulnerable adults. There is evidence that staff make appropriate referrals to the local authority for issues to be considered under safeguarding protocols Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 19 and of taking appropriate action, including staff suspension without prejudice during investigation, and disciplinary measures. The front door is opened by use of a key code pad. Residents do not or cannot open the front door. This must be looked at with the placing authorities under the new safeguards about depriving people of their liberty. This must be done to ensure that any deprivation is being done in the best interests of each resident. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 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): 24, 26 & 30. 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 home is comfortable and clean. Bedrooms are well furnished and personalised. More must be done to ensure that the restricted evacuation procedures for one resident are discussed fully with the placing authority to ensure that there is consideration of her overall safety in the home and suitability of the physical environment. EVIDENCE: The small home is clean, comfortably furnished and well decorated. All bedrooms are single occupancy. There are two ground floor bedrooms, one with en-suite bathroom facilities. There is also a ground floor wet shower room with a separate toilet. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 21 The ground floor has a small communal lounge with a dining area, a small kitchen and patio access to a small rear garden. There is also a small office within the communal lounge and another small office in a garden outhouse. The garden continues to improve and each resident has a small planting area to grow their own flowers or vegetables with staff support. The first floor has four bedrooms, one of which has en-suite bathroom facilities. There is a bathroom with a toilet and a small laundry room. All bedrooms are currently occupied. All bedrooms are well decorated and furnished attractively, some residents need support from staff to personalise their bedrooms. A resident assisted with a tour of the premises and he said that he liked his room and the decorations in his bedroom. All bedroom door locks are lockable and the locks are of a type that can be over-ridden by staff in an emergency. This makes it safer for residents. The rear garden path is reasonably level and there is a handrail fitted. This is of use to one of the residents who is unsteady on her feet. There is a sturdy garden chair and a small covered arbour for one resident who enjoys a cigarette in the garden. There is a programme of decoration and refurbishment in place, and three bedrooms have been re-decorated in the last twelve months. An area of planned improvement is in speeding up repairs and on going maintenance issues. A member of staff said that as a result of physiotherapy assessment one resident is now deemed to be too unsteady on her feet to use the narrow rear garden fire escape route. In a fire evacuation drill she uses the front door escape route only. This must be discussed with her placing authority to ensure that there is consideration of the suitability of the placement in terms of the overall safety of environment. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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): 32, 34, 35 & 36. 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. There is progress in developing a qualified staff team although more must be done to ensure that each member of staff attends all of the training that they need to meet the specific needs of the current residents. Staff recruitment practises provide adequate safeguards. Staff have not been supervised often enough although this is being addressed by the new home manager. EVIDENCE: There are three support workers on duty during the day shifts (morning and afternoon) and two staff on night waking duty. Written shift plans are used to appoint staff to their duties for the day. The registered provider has a training and development programme available and the new home manager is in the process of developing individual training profiles for each member of staff. After this is completed she will be able to develop the required team training plan for the coming year. This must be Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 23 done to ensure that all staff receive mandatory training and training in the specific needs of the current residents. Caretech offer a wide range of training and the manager is able to book new staff on to induction courses and send existing staff for refresher courses. Recruitment records for two new staff members were examined during this inspection. These records indicate that staff are adequately vetted before they are allowed to work in the service. Each member of staff has an enhanced criminal record bureau check in place. There is an induction training programme in place and records show that staff are given training and time when they begin working in the home. Records seen indicate that the frequency of staff supervision and appraisal meetings slipped in 2008. The new home manager has developed a supervision matrix that shares staff supervision meetings between herself and the deputy manager and it is hoped that the frequency will now increase. Annual appraisals are being booked for each member of staff. The majority of staff have now completed or are working towards a vocational qualification in care (NVQ at level 2 or above). This is an area of improvement. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 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): 37, 39 & 42. 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. There has been inconsistent management in the last year. Quality assurance has improved and steps are taken to ensure environmental safety. EVIDENCE: The home has not had consistent management in the last twelve months. A new manager had just started work in the home at the last inspection in June 2008, but only stayed for a few months. A new home manager was appointed recently and she is in the process of registering with the Commission. Interim management arrangements have been in place as an interim measure, with the deputy manager undertaking the majority of home manager tasks. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 25 The registered provider has developed a quality assurance team. A member of the team was visiting the home on the day of the inspection and she explained her role in monitoring the service. The quality assurance team are separate from the operational management team although they meet together regularly to look at how the service can be improved. There is an overall quality assurance report for Caretech services in 2008. This is detailed and was formulated from surveys being sent to relatives, friends and professionals. A survey for residents is going to be sent out in 2009. This is an improvement and will address an outstanding requirement in regards to quality assurance. A representative of the registered provider also conducts monthly inspection visits to the service, in accordance with regulation. The reports are available in the home. The Commission has been notified of events in the home as required. Staff conduct regular health and safety checks on the environment and fire fighting equipment is tested by professionals on a regular basis. Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 X X 3 X Version 5.2 Page 27 Kirkstall Lodge DS0000053104.V374931.R01.S.doc 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 YA1 Regulation 5 Requirement The registered person must revise the service users guide in accordance with recent changes in legislation. Although there is some progress in meeting this outstanding requirement, fee information is still to be added to the guide. 2. YA23 12 The locked front door must be looked at under deprivation of liberty safeguards as residents cannot open the door without staff assistance. Placing authorities must be notified of the restrictions in place for one resident who is too unsteady on her feet to use the rear garden fire escape route. The registered person must ensure that an annual development plan is formulated, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. Previous timescale not met. The registered person must DS0000053104.V374931.R01.S.doc Timescale for action 30/11/09 31/08/09 3. YA24 12 31/07/09 4. YA39 24 30/11/09 5. YA32 18 30/11/09 Version 5.2 Page 28 Kirkstall Lodge YA35 ensures that there is a staff training and development programme which meets the Skills for Care workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’. 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. 2. Refer to Standard YA16 YA19 Good Practice Recommendations The registered person should review the need for keypad access to the home to ensure that residents are not deprived of liberty. Records relating to advised physiotherapy programmes should be completed on a daily basis when the exercises have been completed, as there are significant gaps in current recordings and it is unclear whether the physiotherapy has been provided. There should be suitable storage facilities for controlled drugs in case any are prescribed. 3. YA20 Kirkstall Lodge DS0000053104.V374931.R01.S.doc Version 5.2 Page 29 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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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