Inspection on 17/11/05 for Kathryn Court

This inspection was carried out on 17th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kathryn Court 26/06/07

Kathryn Court 29/09/06

Kathryn Court 13/06/05

Kathryn Court 21/01/05

Kathryn Court 13/09/04

Kathryn Court 27/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Kathryn Court 84 Ness Road Shoeburyness Essex SS3 9DG Lead Inspector Ann Davey & Vicky Dutton Unannounced Inspection 17th November 2005 08.00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kathryn Court Address 84 Ness Road Shoeburyness Essex SS3 9DG 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) 01702 292800 01702 292383 Runwood Homes Plc Manager post vacant Care Home 52 Category(ies) of Dementia - over 65 years of age (52), Old age, registration, with number not falling within any other category (52) of places Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2005 Brief Description of the Service: Kathryn Court is a purpose built establishment accommodating 52 older people. The registration category permits the home to provide care for older people including those with dementia care needs. Kathryn Court has easy access to shops and local amenities. There are good public transport links in the area. Overall, the accommodation and facilities within the home conform to the national minimum standards for existing homes (prior to the NMS). Facilities include 48 single and 2 double bedrooms, all of which have ensuite facilities. There are communal lounge/dining spaces on both floors. The garden/patio area for residents is very limited. There is a reasonable sized car park. Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of 9 hours. As there were two inspectors, this equated to 18 hours input. The inspection focused mainly on the progress the home had made since the last inspection, although other standards were assessed. A partial tour of the home took place. Staff and residents were spoken with. Records were selected at random and various elements viewed. A notice was displayed in the main entrance advising all visitors to the home that an inspection was taking place with an open invitation to speak with an inspector. The Commission is currently processing an application for the position of registered manager from Kariena Robinson (acting manager). The acting manager was on holiday at the time of the inspection. The deputy manager assisted the inspectors. A full and detailed ‘feedback’ was provided during and at the end of the inspection with opportunity for further discussion and/or clarification. A photocopy of the inspectors ‘premises audit’ was given to the home. What the service does well: What has improved since the last inspection? Medication administration recording systems have improved. Residents were wearing appropriate leg covering in accordance with personal choice. The complaints recording documentation was in better order. The amount of agency care staff used has reduced. Residents have been consulted about the ‘timing’ of teatime. There seemed to be more ‘order, control and supervision’ in connection with working practices/systems within the home. The Commission is in receipt of a manager’s application for registration. The findings of this inspection will be discussed with the applicant as part of the registration process. Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 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 Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5 & 6 Documentation associated with pre admission assessments was basic but adequate, the system requires developing. Adequate information was available to inform interested parties about what the home can offer. EVIDENCE: Admission assessment documentation viewed at random was adequate, but the home must ensure that all elements of the document used for this purpose are completed in full. All documentation associated with pre admission activity should be kept on the respective residents record, this includes the respective local authority’s ‘Com 5’ document. The home has a good selection of information in the main entrance area about what services it can provide. There was evidence that whenever possible, visits to the home can be arranged prior to an admission. Kathryn Court does not provide intermediate care. Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 & 11 The information on care plans seen was inadequate, specific care needs known to the home had not been recorded and there were no instructions on these identified documents to enable staff to provide the appropriate care. Care practices to ensure the dignity and privacy of residents have improved. Health/clinical needs are facilitated and medication is better managed, but the current practice of lids being routinely left off topical application containers is not acceptable because of infection control/cross contamination issues. Daily work routines do not provide sufficient gaps in time between medication administration practices. EVIDENCE: Specific and identified care needs had not been recorded on care plans. As a result, there was no instruction on these documents about who to meet these needs. Because of the nature of these care needs, the lack of recorded information and instruction places staff and residents at potential risk. In addition, on other documents, information was missing, was disjointed, had no ‘follow up’/and or did not cross reference with other related documentation. Within the care planning system, the home operates two assessment tools i.e. ‘mental status questionnaire’ and ‘modified barthel score’ (based on physical care needs). The scoring from these two documents is at variance and does Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 10 not provide a holistic outcome. This has crucial implications on the way the home determines staffing levels, as current levels tend to be based on the ‘lower’ score, which is normally associated with physical care needs. The Commission is aware that this current ‘scoring’ is used throughout the establishments owned and managed by the same registered provider. It is also accepted that the registered provider is now aware of the shortfalls associated with the system and is currently reviewing it. As with other homes owned by the same provider, development work is requited on risk assessments as documentation provides an ‘outcome’, but does not adequately demonstrate the process by which a decision is made i.e. to put bedrails in place, night care arrangements. The home recognises the importance of recording residents’ body weights at regular intervals, but has no established process or system in place to monitor and/or address any significant changes. Care plan documentation was noted to have been left unsupervised in the main reception area. This matter was raised with the home at the last inspection. It was positive to note that appropriate entries are now made within the daily ‘handover book’. The home should review current practice concerning the support offered to residents who have recently been bereaved. One identified resident had recently experienced a bereavement, but there was no care plan or documentation in place. The home facilitates appropriate health and clinical care from outside agencies that visit the home on a regular basis. The acting manager said that the home has good working relationship with the different agencies. The medication recording system was in better order and the storage facilities for medication were clean and orderly. Staff who take responsibility for medication issues confirmed that they had received adequate training. It was of concern to note the number of topical applications (creams & lotions) had been left without lids and with no names on them in a number of ensuites. Of particular concern was one application container belonging to a previous resident, the contents of which were seemingly in use and being used for another resident. Full details were given to the acting manager. The morning medication ‘round’ is often not completed on some days until 10.30am. This of concern because the next ‘round’ is carried out at lunchtime and potentially there may only be a gap of 2.5 hours before another dose of the same medication is given. The home must also ensure that when a resident is cared for in bed for significant periods of time, adequate infection control measures are put in place i.e. liquid soap and paper towels. The home has significantly improved on care practices which promote residents dignity, but issues such as wearing white plastic coverings at mealtimes need to be addressed. Staff were also observed to be carrying out ‘moving & handing’ tasks in a dignified, sensitive manner. Staff in general were noted to interact well with residents, but staff recruited from abroad need to develop their skills as interaction tended to be task orientated. Residents were Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 11 generally very positive about staff and the care they provide. Staff spoken with aware of residents’ general care needs. Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 The home has an effective social/activities programme in place. There are established links with the local community. Systems need to be developed to enable residents to exercise more choice and control. Residents are provided with a choice of food at mealtimes. EVIDENCE: The home has an established Monday – Friday activities/social events programme in place. This clearly is one of the homes main strengths. The home facilitates group activities, outings, community events, as well ensuring that the social needs of individual residents are also met as appropriate. On display throughout the home was the current weeks activities programme. It was varied, interesting and accurate. Residents’ clearly enjoy the activities and events on offer and/or are facilitated. The inspection coincided with a routine visit by the hairdresser. This activity was clearly enjoyed by the residents. Daily routines within the home tend to be task orientated. Whilst it is accepted that work practice systems need to be in place, there was no establish practice whereby residents are given the choice of when they get up or go to bed particularly when/if they are reliant on staff assistance. Several residents shared this view. The home must give further consideration to individual choice Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 13 and allow residents where appropriate, to have more control over the daily routines which affect them personally. Records demonstrated that residents have choice of food at all mealtimes. The desserts of the day looked particularly appetising. Residents were positive about food provision. Mealtimes were noted to be unhurried and a number of residents were still enjoying their breakfast at 9.15am. Staff should not only record the choice of meal eaten for each resident, but also the quantity eaten. It is important to monitor this as part of the care process - see the ‘health & personal care’ section of this report re body weight monitoring. It was disappointing to note that residents are still wearing white plastic apron coverings at mealtimes. The home should also give consideration to the way tables are laid for meals to perhaps promote a more homely environment. The wooden tables used, had no tablecloths or protective mats on them. As noted at the previous inspection, food was presented ‘pre portioned’ i.e. there was no choice over what size of desert available, whether or not gravy was required or size of appetite. Portions were all the same and there was a lot of waste. The home must ensure that it has an adequate supply of drinking containers for residents. The inspector observed a member of staff removing used plastic beakers from the lounge area, rinsing them out in a residents bathroom, they were not dried and then put on tables ready for lunch. This practice is not acceptable as there are infection control/hygiene issues. The member of staff said that there was a shortage of beakers. Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Staff had an acceptable knowledge base and understanding of adult protection issues. A complaints procedure is displayed in the main entrance area. EVIDENCE: Staff spoken with had an adequate basic awareness of adult protection procedures. Further training dates with identified staff members listed to attend, were displayed in the staff room. The home’s complaints procedure was on clear display in the main entrance area. The acting manager said that there have been no complaints recorded since the last inspection. An appropriate documentation/recording system was in place should it be needed. Residents spoken with said that they would be happy to raise any concern with the home. Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24,25 & 26 Generally the environment was clean, comfortable and pleasant, but identified aspects need attention for the comfort, wellbeing and safety of residents. There is a lack of orientation and directional signage throughout the premises. EVIDENCE: The main entrance to the home is welcoming and contains many items of useful and helpful literature to help residents and visitors. This area in particular, is bright and airy. In the main, residents’ bedrooms and communal areas were reasonably decorated, furnished and equipped. The vast majority of the bedrooms were very personalised, creating a warm homely atmosphere. It was evident that some areas of the home require redecoration, repainting and outdated/worn furnishing need to be replaced. There were isolated areas of poor odour management, but in general it was good. The call bell system was tested and the response time was good. The home should ensure and demonstrate that it has adequate communal space that is compliant with the national minimum Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 16 standards. The designated visitors room is now used to store social activity equipment and the visitors’ facility now doubles with a communal area on the 1st floor. Consideration must be given to this new arrangement and assure the Commission that no compromise has been made. A ‘premises audit’ was carried out by the inspectors and a photocopy of the findings was left with the home. A number of shortfalls were identified and noted, these include issues such as call bells not being accessible, no mattress covers, a lack towels in ensuites, colour caps missing on taps, light switches broken, furniture broken, bin lids missing, extractor fan casings dirty and broken toilet roll holders. Full details were recorded in the document given to the home. Of particular concern to the inspectors’ was the number of potential health and safety hazards noted. For example, the home accommodates residents with dementia, yet latex gloves and plastic aprons were left around and easily accessible, soiled bed linen was left in direct contact with clean bed linen, staff performing care tasks with no protective covering over the personal clothing, no paper towels in the laundry area, yellow hazard cones routinely left around the home, topical applications (creams) left in ensuites with no lids, no systematic approach to the cleaning of baths after use. Full details were noted in the document given to the home. The home is registered to provide care for residents with dementia, but there was a lack of orientation/directional signage and or colour coding to assist/help residents. Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Staff recruitment files, the current staff rota and staff induction records were inadequate. Staffing levels must be reviewed in the light of the identified shortfalls with the home’s current assessment scoring tools and designated workload. EVIDENCE: The inspection coincided with the acting manager’s holiday. The deputy manager ably assisted the inspectors. Throughout the day, staff were helpful and cooperative. Staff were positive in their outlook and moral was generally good. Residents were positive about the attitude of staff. Since the last inspection, the home has developed better working practice systems. There seemed to be more control and order in the daily staffing arrangements and delegation of work. In general, residents were well supervised by staff, but there were long gaps when residents were left to their own devices. This was mainly in the afternoon and coincided with the ‘handover’ period. Many residents have dementia care needs and it is not safe to leave residents unattended. It was positive to note that the home is no longer reliant on agency care staff. It was however noted that some staff are ‘contracted’ to work double shifts. This is not good practice. The home did not have a ‘working rota’. The inspectors were given a ‘master rota’ which was not accurate as it showed staff on sick leave and staff that had left the employment as being on duty. It was established that if anybody wanted to know who was on duty at any one time, at least 3 different pieces of Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 18 documentation had to be deciphered, together with other information held on the computer. The deputy manager confirmed that to determine who was on duty at any point would be time consuming, and unless a person was familiar with the process, the exercise would be difficult. Current practice is not acceptable as rota’s were not accurate in detail and content, and the system used is confusing and open to interpretation. The inspectors were unable to understand and establish the current situation. Concerns about the presentation of the staff rota were noted at the last inspection and have not been addressed. The home should also review the number of senior staff on duty at weekends and their workload. There is normally only one senior member of staff on during the day at weekends, there is no administrative support, they are required to ‘manage’ the care of 52 residents, administer medication which can take up to 2.5 hours, supervise staff and deal with visiting professional and visitors. This has been raised with the home on previous occasions. The staff recruitment files selected were inadequate. For example, there were variances between posts applied for, contracts offered and role/status actually undertaken, references were missing, induction documentation was not in place, there was no documentation concerning work permits and start dates were unclear. Full details were discussed with the deputy manager. Concerns about the presentation of staff recruitment records were noted at the last inspection and have not been addressed. The deputy manager said that training opportunities had been ‘patchy’, but it was getting better. Staff said that they had received some training, records were not examined on this occasion. A senior member of staff continues to be designated as the deputy manager. However, in reality the rota shows that only 1 shift (8 hours) per week is solely for this role. The remainder of the time is spent fulfilling senior carer tasks. At the last inspection it was noted that there are no domestic staff on duty in the afternoons and evenings. Any domestic duties have to be carried out by care staff. This would distract them from their care duties. It was reported that this practice was not acceptable considering the size of the home i.e. 52 residents. This has not been addressed. The deputy manager said that the home currently has the following vacancies: day care hours = 50, domestic hours = 30, laundry hours = 16 and kitchen hours = 14. The home has a dress code and jewellery policy. The home should review this for compliance, as the manner in which some staff presented themselves was not professional and/or could potentially injure a resident. The home accommodates residents which challenging behaviour patterns and some items of decoration and jewellery worn by staff could be a potential risk. Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,35,37 & 38 A number of shortfalls associated with staff recruitment records, staff rotas and care plan documentation have not been addressed since the last inspection. Some of these shortfalls could potentially place residents at risk. Local management strategies need to be revised and further developed. EVIDENCE: The home does not have a registered manager in place at present, but the Commission is currently processing an application. The acting manager has been in post for 5 months. It is of concern that a number of shortfalls identified at the last inspection remain and there is a element of risk because of this. Whilst there seems to be a more developed and supervised work pattern system now in place, the management and processing of some daily documentation/recording systems is inadequate and does not meet regulatory requirements or the national minimum standards. Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 20 Staff reported a good working relationship with the acting manager and found her approach positive and open. The system whereby residents’ personal monies are kept and transactions are recorded was sampled. Documentation was in good order and the monies in safe keeping equated with the stated amounts. There is no registered manager at the moment, therefore the registered provider must give careful consideration to the content of this report and provide every assistance and support to the acting manager to address the identified regulatory shortfalls and raise standards to ensure that residents welfare, safety and wellbeing are upheld and promoted. Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 21 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 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X X 3 2 2 2 STAFFING Standard No Score 27 1 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 2 2 X 3 X 2 2 Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 22 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 OP11OP7 Regulation 15 Requirement The registered person(s) must ensure that all residents have a comprehensive plan of care. This must include details of the care required, risk assessments, an adequate assessment of dependency level(s), care plan review and adequate daily records. Records must be kept in accordance with regulatory requirements and the NMS. The previous timescales of 21/2/05 and 13/7/05 have not been met. This is the 5th repeat requirement. The registered person(s) must ensure that all medication administration practices within the home are in accordance with guidance. This is with reference to the shortfalls noted concerning topical (creams & lotions) applications. A full review must also take place concerning the ‘time gap’ between the morning and lunchtime medication administration routine. DS0000015442.V259748.R01.S.doc Timescale for action 31/12/05 2 OP9 13 31/12/05 Kathryn Court Version 5.0 Page 23 3 OP14OP15 OP10 16 3 OP15 16 4 OP26OP25 OP24OP20 OP19 23 The previous timescales of 21/2/05 and 13/7/05 have not been met. This is the 3rd repeat requirement concerning medication related issues. The registered person(s) must 31/12/05 ensure that the privacy, dignity and choice of residents are upheld at all times. This is with reference to daily personal care routines, residents wearing appropriate protective covering in the dining areas and residents personal care records being left unattended in the main reception area. The registered person(s) must 31/12/05 ensure that adequate records are maintained concerning the quantity of food eaten by residents. This had direct implications on the practice of measuring body weights as referred to within standard 7 of this report. At present there is no established process by which these recorded body weights and quantity of food eaten can be correlated. 31/12/05 The registered person(s) must ensure that the home is in a good state or repair, be safe and maintained in accordance with regulatory requirements and the NMS. The home is registered to provide care for residents with dementia. Adequate orientation and directional signage must be in place to assist these residents. Systems must be put in place immediately to address the identified hazards for the safety, comfort and protection of residents. Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 24 5 OP30OP29 OP28OP27 18 & 19 A programme timescale of repair, replacement, redecoration and maintenance must be sent to the Commission. The registered person(s) must/ensure: Review and be able to demonstrate that sufficient staff are on duty at all times to fully meet residents assessed needs. Staff recruitment records must be maintained in accordance with regulatory requirements. (This is the 5th repeat requirement.) Staff rotas must be accurate. (This is the 2nd repeat requirement.) A process by which a full review of the home’s dependency level assessment tool(s) must take place. The outcome of this may have an impact on current staffing levels. Evidence of staff induction must be kept current and available. There is no domestic cover in the afternoon and evenings. These duties are currently covered by care staff which distracts them from their care duties. This practice must be reviewed. The deployment and responsibilities of workload for senior staff particularly at weekends be reviewed. The registered person(s) must give serious consideration to the repeated shortfalls identified within this report for the safety, comfort and wellbeing of DS0000015442.V259748.R01.S.doc 31/12/05 6 OP38OP37 OP33OP32 12,13 & 24 31/12/05 Kathryn Court Version 5.0 Page 25 residents. In the absence of a registered manager, local management strategies must be reviewed as appropriate. Although a timescale has been set, this requirement is immediate and ongoing. 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 3 Refer to Standard OP4OP3 OP15 OP29 Good Practice Recommendations The registered person(s) should ensure that the pre admission/admission procedures are developed as detailed with the report. The registered person(s) should give further consideration to the manner in which tables are laid at mealtimes and food is presented. The registered person(s) should ensure that a review of the home’s ‘employees - jewellery policy’ takes place. The style of jewellery and personal decoration worn by staff on duty should not present as potentially harmful to themselves and/or residents. Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kathryn Court DS0000015442.V259748.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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