Inspection on 04/05/06 for Kathryn`s House

This inspection was carried out on 4th May 2006.

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`s House 24/09/07

Kathryn`s House 06/10/05

Kathryn`s House 09/06/05

Kathryn`s House 13/12/04

Kathryn`s House 17/06/04

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

CARE HOMES FOR OLDER PEOPLE Kathryn`s House Kathryn`s House 43-47 Farnham Road Guildford Surrey GU2 5JN Lead Inspector Helen Dickens Unannounced Inspection 4th May 2006 10:00 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`s House DS0000013687.V293058.R01.S.doc Version 5.1 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`s House DS0000013687.V293058.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kathryn`s House Address Kathryn`s House 43-47 Farnham Road Guildford Surrey GU2 5JN 01483 560070 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) Mrs Z Z Merali Mrs Denise Hoare Care Home 29 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (29), of places Physical disability over 65 years of age (1), Sensory impairment (2) Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Of the 29 residents accommodated, up to 10 may fall within the category DE(E). Of the 29 residents accommodated, up to 1 may fall within the category PD(E) Of the 29 residents accommodated, up to 2 may fall within the category SI(E), as registered partially sighted. The age range of Service Users will be 65 Years and over. Date of last inspection 6th October 2005 Brief Description of the Service: Kathryn’s House is a large terraced house in the town centre of Guildford. The service provides care and accommodation for up to 29 older people, ten of whom have dementia. The accommodation is on four floors with a lift to access the upper floors of the home. The lower ground floor is accessible only by a staircase and therefore accommodates residents who are fully mobile. The home has an outdoor area at the rear of the home which needs further work before residents can sit outside in safety and comfort. There is also a small area set aside for parking. Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 8 hours and was the first inspection to be undertaken in the Commission for Social Care Inspection year April 2006 to March 2007. The inspection was carried out by Mrs. Helen Dickens, Link Inspector for the service. Mrs. Denise Hoare, the Registered Manager, and Mr. and Mrs. Merali, the owners, represented the establishment. A partial tour of the premise took place and a number of files and documents, including residents care plans were examined as part of the inspection process. Four residents were interviewed and six others spoken with during the day. In addition one relative and one visiting professional were interviewed, and a number of questionnaires returned from relatives were also considered. The inspector would like to thank the residents, relatives, staff and owners, for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? The majority of Requirements made at the last inspection have been met including all care plans have now been updated and were being regularly reviewed. The community pharmacist’s visit had been chased up and when the visit was made, Kathryn’s House were given a good report regarding the way they store and administer medication. The help available at mealtimes for Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 Page 6 residents who need assistance was reviewed and this is detailed later in the report. The home has restarted its annual quality assurance work and this is also discussed later in the report. A new and modern lift was being installed on the day of the inspection and due to be completed within the week. The kitchen, storeroom and staff toilet has been completely refurbished with new tiling, shelving and decoration. The dining room has also been redecorated and is much brighter than previously noted. New flooring has been put in the main hallway to the dining room and office. Following advice regarding suitable environments for those with dementia, this floor covering is plain cobalt blue, and contrasts with the white skirting boards to minimise confusion for residents. The arrangements for activities at Kathryn’s House continue to improve and the senior staff member responsible for this area continues to show enthusiasm and commitment to the task; progress made since the last inspection is detailed later in this report. Staff have continued to undertake relevant training and one has had a two-day course on activities for people with dementia, whilst others are attending general courses on dementia and the administration of medication. 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 Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 Page 7 contacting your local CSCI office. Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Kathryn’s House carries out good basic assessments on new residents to ensure their needs have been properly identified. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Those resident’s files examined showed that residents had had an assessment of their needs carried out prior to, and in the early days of admission. These were properly completed and formed the basis of their care plans. Those admitted under social services community care arrangements also had a community care assessment of need on their file. Kathryn’s House does not offer intermediate care. Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Residents care plans gave a good overview of their needs and were reviewed regularly; their health and social care needs were properly documented. Medication administration is well organised at Kathryn’s House. Residents were observed to be treated respectfully. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The remaining care plans have been brought up to date and all kept in a standard format, in individually coloured ring binders for ease of use. The four examined showed a good overview of each resident’s health and social care needs and how these were to be addressed. They had all been reviewed on a monthly basis. Discussions with one community professional on the day of the inspection, and another prior to the inspection, showed Kathryn’s House has some good relationships with health and social care professionals for the benefit of residents. The home was praised for the standard of care they had offered to Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 Page 11 individual residents and one professional thought the staff at Kathryn’s House had been ‘exemplary’ with regard to the way they had looked after one resident in particular. Residents spoken to confirmed they were being well looked after. However, one resident was overheard to be disappointed because she had not been given the bath she was promised before going out; the manager immediately went to see if this could be arranged but it was too late. A comment on a questionnaire from a relative noted that some residents were only down for one or two baths per week on the ‘bathing rota’. The manager said this may have been their choice, and some residents had a shower which would not be on the bathing list. It is recommended that the bathing arrangements be reviewed with regard to the above, and that bathing ‘rotas’ could be considered institutional and not sensitive to the individual needs of residents. If rotas are being used for the moment, they should be kept in a way which would protect the privacy and dignity of residents. Kathryn’s House operates a ‘key worker’ system but on the relative’s questionnaire, one relative commented that they didn’t know who the key worker was. This needs to be addressed, as liaising with relatives is a useful tool in the key working process. Medication was well administered and the last community pharmacist’s report was good. Medication was found to be stored securely, the medication records were accurately kept, and there was ‘excellent control of stock’. Some resident’s medication needed to be reviewed by their GP and this had been carried out. Resident’s were observed to be treated respectfully during the day of this inspection. Arrangements in the laundry ensure resident’s clothes are kept and returned separately, and arrangements for personal care ensured privacy. Residents were addressed politely and were observed to approach staff when they needed assistance. Staff interviewed had a positive and respectful approach to residents and said that recent dementia training had helped them to have a better understanding of resident’s behaviour and respond more appropriately. Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 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 and 15 Opportunities for activities continue to improve at Kathryn’s House. Contact with family and friends is encouraged and residents are helped to exercise some choice and control over their lives. Residents continue to be pleased with the food provided at this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Activities have improved over the last year in a number of ways. Some regular activities are now in place for example a fortnightly session with a visiting pianist and regular sherry and nibbles sessions. Records are kept of all the activities and who joins in, so that it isn’t just the same few people who join in while others are left without stimulation. On the day of the inspection the member of staff who overseas the activities arrangements showed the inspector exactly what the residents who were being ‘case-tracked’, had participated in during the last two weeks. Activities included walking by the river and feeding the ducks, arranging for a resident and some interested others to watch a war film together, and all gathering around the TV for sherry and nibbles to watch the Queen when she visited Guildford. All activities are recorded for individual residents and for these four Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 Page 13 residents it had included visits from family and friends, one-to-one sessions with staff, and joining group activities. Staff had noticed that residents were now more sociable with each other, and the ‘activities for people with dementia’ training course had helped staff better understand ‘person-centred’ approaches for stimulating residents. Hopefully the outdoor area will be made comfortable and safe for residents by the summer, and some activities will be planned for them in the fresh air. The home already holds an outside barbecue for residents in the summer. A recommendation will be made that the home review their work on activities during the year, both for individual residents and overall – this will help with making future plans and provide an opportunity for residents and staff to appreciate the progress which has been made and make a useful contribution to the home’s quality assurance processes. Residents are encouraged to take advantage of community facilities; some attend day centres, others go into town using taxis or go with family and friends. Staff were knowledgeable on the involvement of family and took seriously the concerns of family members. The recent quality assurance exercise had brought in a variety of comments from relatives and the manager was devising a list of priorities for action. The manager is also trying to find ways to involve family and friends more, and is hoping to arrange a joint residents and relatives meeting. Meals at this home continue to bring compliments from residents. One said the food was ‘excellent and plentiful’ – another told the inspector she had just had a very good meal, and commented on how tender the liver was. One resident came out of the dining room and went straight over to the manager to tell her how much he had enjoyed his ‘dinner’. On the day of the inspection it was home cooked liver and bacon with fresh cabbage and sweet corn; the alternative was a baked potato with cheese and salad. The cook had made a jam tart with custard for pudding. All residents spoken to enjoyed their food. The menu is well planned, special diets are catered for, and those having soft or liquidized food had each item liquidised separately and then arranged on the plate to look exactly like everyone else’s lunch. The dining room has been redecorated and is now much brighter, and there were staff available to help residents who needed assistance to eat. Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 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 and 18 Complaints are taken seriously at this home and staff are aware of their responsibilities for protecting vulnerable adults. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no official complaints made to the home since the last inspection. Residents spoken to were aware of how to raise issues informally, and staff reported that a number of residents are very confident in highlighting any problems they have. The recent questionnaires to relatives have also highlighted a number of areas which need attention. One anonymous complaint was received at CSCI about Kathryn’s House since the last inspection and the providers of the service were asked to investigate this in the first instance. Some of the issues raised were upheld and the home has rectified these. The home kept CSCI informed and the inspector was satisfied that the home had dealt with this correctly. The home has a copy of the Surrey multi-agency procedures for the protection of vulnerable adults and staff have had protection of vulnerable adults (pova) training. There have been no POVA matters raised since the last inspection. The manager is aware of her responsibilities in relation to reporting such matters. Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 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 and 26. The home is generally well maintained but some maintenance and decorative matters, and the long overdue issue regarding the outdoor area need to be rectified in order to meet these Standards in full. The home is generally clean and hygienic but a number of areas needed attention on the day of the inspection. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The owners continue to maintain and renew furnishings, fittings and decoration. A new and modern lift was being installed on the day of the inspection and due to be completed within the week. The kitchen, storeroom and staff toilet has been completely refurbished with new tiling, shelving and decoration. The dining room has also been redecorated and is much brighter than previously noted. New flooring has been put in the main hallway to the dining room and office. Following advice regarding suitable environments for those with dementia, this floor covering is plain cobalt blue, and contrasts with Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 Page 16 the white skirting boards to minimise confusion for these residents. Furnishings in this home are domestic in character, and of good quality and the communal areas provide a variety of areas for residents to enjoy. The home has fitted very good quality radiator covers which enhance the look of those rooms they occupy. However, maintenance and decorative work is needed in the downstairs toilets and the laundry. One toilet needs a replacement floor covering and the paintwork needs renewing. The light fitting and casing over the light outside one toilet was hanging off. One resident’s room had been fitted with a central light, but there was no light shade. The outdoor space (there is no garden at this home) is currently not available to residents due to the lift replacement and builder’s materials being left outside. This work should be finished within a week but the outdoor space has not been refurbished as per the Requirement made at the last inspection. Standard 19.3 says; ‘Grounds are kept tidy, safe, attractive and accessible to service users, and allows access to sunlight.’ Standard 20.3 says; ‘There is outdoor space for service users, accessible to those in wheelchairs or with other mobility problems, with seating and designed to meet the needs of all service users including those with physical, sensory and cognitive impairments.’ These are ‘minimum’ standards and Kathryn’s House currently does not meet them in relation to outdoor space. A new Requirement with a shorter timescale will be made in this regard. The home is generally clean and hygienic with suitable hand washing facilities; laundry and sluicing facilities are also provided. However, the laundry room needs to be thoroughly cleaned as the machines and sinks were covered in washing powder and stains, the area at the back of the machines has a thick covering of powder, the bin was overflowing, dirty vases were soaking on the sinks and dirty mops left out. The floor is not impermeable and the areas of paint on concrete have been damaged – it would be difficult to keep this floor in a hygienic state even with much higher standards of cleanliness. The lino floor covering has ‘joins’ which would also let in bacteria and be difficult to keep clean. The floor covering needs to be reviewed. There were no towels in the paper towel holder. One corridor and bedroom in the home were not free from unpleasant odours and this was discussed with the manager. She said some new mattresses were being purchased as at least one had a tear in the waterproof covering. A downstairs toilet had no lock and no hand basin, nor did it contain any hand gel or wipes. Requirements will be made on all these matters. Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 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 and 30. Resident’s needs are catered for at this home but more work needs to be done on the recruitment policies and practices. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is currently working on the Residential Forum matrix to calculate staff to resident ratios. This should be sent to CSCI once completed. Additional staff are on duty at peak times. Residents reported their needs were being met and observations for example during lunchtime, showed there were sufficient staff to provide assistance to residents who needed it. Training is taken seriously at Kathryn’s House; more than 50 of staff now have NVQ2 or above. Training certificates are framed and displayed in the home, particularly in the office, and staff had undertaken a variety of training courses since the last inspection including dementia care training, and one staff member had been on an activities course for working with people with dementia. New staff were receiving induction training and these records were viewed as part of the inspection process. Though some recruitment files were well done, others were incomplete. Some practices needed reviewing and these were discussed with the manager for example friends should not be given as referees; all references must be placed on staff files; and it is not good practice to get both references from the same Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 Page 18 company. Not all employees files showed a full employment history, as set down in the Care Homes Regulations. In addition, two new staff were working without having had a POVAfirst check, to ensure they are not on the protection of vulnerable adults register. There was also no evidence that Criminal Records Bureau checks had yet been applied for. An Immediate Requirement was made in this regard though the owner gave assurances the staff involved would not be on duty again until the POVAfirst checks had been carried out and when they returned to duty, they would be properly supervised as per the Care Homes Regulations. Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 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): 31,33,35,36 and 38. The new manager is discharging her responsibilities well. Quality assurance systems are in place though further work will be needed to meet this standard in full. Resident’s finances are safeguarded. Formal staff supervision needs to be more frequent. Health and safety matters are taken seriously but more work will be needed to fully protect residents. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new manager has been working in care settings for two decades and was the deputy manager at Kathryn’s House before being promoted. She is currently studying for the Registered Manager’s Award. She has also made good progress in terms of meeting the previous Requirements and Recommendations. Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 Page 20 The home have some measures in place to test and monitor the quality of their service for example the owners carry out Regulation 26 visits to the home on a monthly basis and there are regular resident’s meetings held at the home. They have also recently devised and sent out a questionnaire to 10 relatives asking their opinions on a variety of topics. The manager is now devising a list of priority areas for action as a result of the feedback received. The home also needs to gather feedback from other stakeholders including local health and social care professionals involved with the home. The home must devise and send to CSCI, an annual development plan, and consider how Kathryn’s House meets all aspects of Standard 33. Though there was no time to check resident’s finances at this inspection, on previous inspections this area has been found to be well managed with systems in place to protect residents. The staff at this home work hard to make the home safe for residents. On the day of the inspection the hazardous substances cupboard and the laundry were securely locked. Many of the repairs carried out since the last inspection had improved health and safety, such as refurbishing the kitchen and staff toilet, and providing new and easily cleanable shelving in the dry store. All but one of the actions required at the recent Environmental Health Officer’s inspection had been carried out. There were a number of health and safety concerns on the day of the inspection including a temporary ramp being used indoors so that residents avoided passing through the area where the lift was being replaced; but it was not high enough and residents were not used to taking this diversion so a number of ‘near-misses’ were observed as residents used the ramp. Staff were already keeping an eye out but the hazard was pointed out to the owner who then arranged for staff to remain by the ramp continuously. The inspector asked for a risk assessment to be carried out. The fridge in the dry store was not maintaining a sufficiently low temperature to satisfactorily store chilled food – it was suggested that food requiring chilling be kept in the other fridge. The recent Environmental Health Officer’s report commented on the fridge’s seal and the owner’s were already considering a replacement fridge as a new seal was not available. The laundry area has been discussed earlier in the report but the manager must also seek advice on the proximity of the sluicing facility to the internal wall and window which opens into the kitchen. Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 1 X X X X X 1 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 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 OP19 Regulation 23(2)(b) (d) 13(3) Requirement The responsible individual must review the maintenance issues in the laundry and downstairs toilets as outlined in this report. An action plan regarding the remedial action to be taken, and the timescales, must be sent to CSCI. The outdoor area must be refurbished to provide safe, accessible and pleasant surroundings where residents enjoy fresh air and sunshine. An interim report on progress should be sent to CSCI by 04/06/06. Outstanding from 06/02/06. The laundry area must be thoroughly cleaned to remedy the issues identified under this Standard earlier in the report. This should include the floor, which needs particular attention until a decision is made and action taken regarding a more suitable floor covering. The offensive odours in one hallway and bedroom must be dealt with urgently as discussed DS0000013687.V293058.R01.S.doc Timescale for action 04/06/06 2. OP20 23(2)(b) (o) 04/07/06 3. OP26 23(2)(d) 13(3) 11/05/06 4. OP26 23(2)(d) 13(3) 05/05/06 Kathryn`s House Version 5.1 Page 23 5. OP26 23(2)(j) 12(4(a) 13(3) 6. OP29 19(1)(b) 13(6) 7. OP29 19(9)(10) (11) 7. OP33 24(1)(3) 8. OP36 18(2)(a) 9. OP38 13(4)(a) (c) with the manager. The timeliness of providing replacement mattresses must remain under review to prevent this situation from recurring. The arrangements for the use of the downstairs toilet near the dining room should be reviewed, as there was no lock on the door, and no hand basin or means of cleansing hands after using the toilet. All persons employed in the home must have a POVAfirst check carried out before employment commences, to ensure they are not identified on the protection of vulnerable adults register as unsuitable to work with vulnerable people. Immediate. All persons employed at the home must have applied for an enhanced Criminal Records Bureau check. Staff whose checks have not yet been received may work in the care home only in accordance with the Regulations. Immediate. The responsible individual must continue the annual quality assurance audit and include opinions from all stakeholders as set out in the report. The responsible individual must identify how they are complying with each aspect of Standard 33 and send a statement, setting this out, together with a copy of the annual development plan to CSCI. The responsible individual must ensure that all staff have formal and documented supervision at least 6 times per year. The responsible individual must ensure a risk assessment is DS0000013687.V293058.R01.S.doc 05/05/06 04/05/06 04/05/06 04/07/06 04/06/06 05/06/06 Page 24 Kathryn`s House Version 5.1 10. OP38 13(4)(c ) 11. OP38 13(4)(c ) carried out and remedial action is taken regarding the temporary use of the ramp which resident’s are using to avoid the area where the replacement lift is being fitted. The fridge in the dry store should 05/05/06 not be used to store chilled foods which require refrigeration at or below 5C, as it is currently not operating at that temperature. The responsible individual must review the arrangements regarding refrigeration and ensure proper arrangements are made. The responsible individual should 05/06/06 seek advice from the environmental health department regarding the arrangement of the sluicing facility in the laundry room and the proximity of an internal window which may be opened into the kitchen. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations The home should consider taking specialist advice on activities for people with dementia and on presenting information, including the activities programme and complaints procedure, into a format which is more accessible to these residents. The home should consider taking specialist advice on the environment, especially the outdoor area, before updating/refurbishing the home further. The home should complete the Residential Forum matrix DS0000013687.V293058.R01.S.doc Version 5.1 Page 25 2. OP19 3. OP27 Kathryn`s House to calculate staff to resident ratios. Kathryn`s House DS0000013687.V293058.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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`s House DS0000013687.V293058.R01.S.doc Version 5.1 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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