Inspection on 06/10/05 for Kathryn`s House

This inspection was carried out on 6th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kathryn`s House 24/09/07

Kathryn`s House 04/05/06

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 Announced Inspection 6th October 2005 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.V256478.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`s House DS0000013687.V256478.R01.S.doc Version 5.0 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 To be confirmed 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.V256478.R01.S.doc Version 5.0 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 9th June 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 who 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 with a covered seating space for residents and staff to sit outside; this is due to be refurbished during the coming winter months. There is also a small area set aside for parking. Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 7 hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Helen Dickens, Lead Inspector for the service. Mrs. Denise Hoare, the new manager, and Mr. And Mrs. Merali, the owners, represented the establishment. A tour of the premises was undertaken and a number of documents and records examined. Four residents, two staff and a visiting community professional were interviewed. A pre-inspection questionnaire and a number of returned ‘comment cards’ were also considered in writing this report. This was a very positive inspection. The inspector would like to thank the residents, staff and owners of Kathryn’s House for their time, assistance and hospitality during this inspection. What the service does well: The service has a committed staff team and supportive management who work hard to create and maintain the homely atmosphere at Kathryn’s House. There was a very positive reception for the inspection process and, as happened at the last inspection, the owner had work carried out in the afternoon, which the inspector had only requested that same morning. Residents were complimentary about the standard of service they received and a resident who had moved in since the previous inspection in June said ‘ I like it very much at Kathryn’s House…I want to stay.’ Residents commented particularly on the food and the cook was complimented on the standard of cuisine provided at Kathryn’s House. A visiting community professional commented very favourably on the staff and the way they provided care to residents. More details on this appear in the main report. There is an ongoing programme of refurbishment which keeps the internal decoration and furnishings to a good standard; some of the many improvements since the last inspection are highlighted below. Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: New Requirements and recommendations have been made including; upgrading the staff facilities (toilet area); replacing storage shelves in the store room; carrying out some minor repairs in the kitchen area as well as considering using contract cleaners for deep cleaning of the kitchen; decorating the dining room; and reviewing the outdoor facilities. Care plans have improved but some more work needs to be done. Mealtimes at the home need to be reviewed to make sure residents who need assistance are given timely and appropriate support; the home should consider taking specialist advice on this. The visiting community pharmacist has not visited for some time and this must be chased up. Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 7 Some missing policies need to be produced and others revised, to ensure they reflect what is currently happening at the home. The home should consider putting some existing policies/documents into a format which is more accessible to residents who have dementia and therefore may no longer be able to read. The internal quality assurance programme is behind schedule and should be restarted to ensure resident’s views are sought and taken into account. 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`s House DS0000013687.V256478.R01.S.doc Version 5.0 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.V256478.R01.S.doc Version 5.0 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): 2 and 3 Residents at Kathryn’s House can be confident that the terms and conditions of their stay will be properly set out, and their needs assessed, prior to admission. EVIDENCE: The resident’s files sampled showed contracts had set down clearly the conditions of staying at Kathryn’s house. Those residents with social services funding also had a social services contract with the home. Those contracts sampled had also been signed by the resident. Needs assessments had been carried out prior to admission and the new residents confirmed that they were being well looked after at the home and their needs were being met. Relevant professionals have an input into the assessments and those residents with a care manager had social services assessments and reviews on their files. Standard 6 is not assessed at Kathryn’s House, as intermediate care is not provided. Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 10 Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Resident’s care plans have improved and this work needs to continue in order to fully meet this Standard. Medication practices were good but the outstanding pharmacy inspection needs to be arranged in order to properly protect residents and staff. EVIDENCE: Much work has been done on resident’s care plans since the previous inspection. Those plans, which have been transferred into the new format, provide a good overview of residents needs, are easier for staff to manage, and are in a more accessible format for most residents to read. Those examined had been appropriately reviewed. More work needs to be done to make sure all residents have these new plans and they are complete, up-todate and regularly reviewed. The new care plans had clear information about the community professionals involved in the care of residents. A visiting professional, involved in the care of some residents at the home, arrived during the inspection. She was complimentary about the way the staff at Kathryn’s House supported residents. She said in her experience, the staff never ‘flap’, and she did ‘admire them for their ability to keep calm.’ She also remarked that they had a good Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 12 relationship with the consultant and always followed advice regarding resident’s care. She had never had to make a complaint about the home. The home has made good progress with regard to residents with incontinence and procedures have been put in place to support residents appropriately. Though there is no overall continence policy, there is plenty of evidence from resident’s files and speaking with staff, that individual resident’s continence matters have been assessed and are being kept under review. The inspector observed the lunchtime administration of medication and noted that the member of staff performing this task was competent and knowledgeable about what she was doing. The medication administration records examined were well kept and had no gaps in recording. There are currently no controlled drugs in the home. Past inspections by the visiting community pharmacist highlighted very few concerns and the home always reviewed their procedures in line with any advice given. However, the home is entitled to two visits per year from the visiting community pharmacist and the last recorded visit was December 2003. A visit from the community pharmacist ensures an ‘expert’ opinion on the storage and administration of medication, and provides a ‘check’ to make sure current best practice is being followed. Only one resident self-administers medication and a risk assessment needs to be in place in this regard. On the day of the inspection residents were observed to be treated with dignity and respect by the staff at Kathryn’s House. Screening in one room has been revised to ensure privacy for both residents. The laundry facility is arranged so that residents can be confident they will have only their own clothes returned to them. Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15. Residents are benefiting by the increase in the number and level of social activities at Kathryn’s House. The meals at the home were of a good standard and much appreciated by residents but mealtime experience for some residents needs to be improved in order to fully meet this standard. EVIDENCE: There have been significant improvements in activities at Kathryn’s House since the previous inspection. Staff have had more training, and two members of staff have taken responsibility for the social and recreational activities. One staff member has compiled an activities folder with information about what each resident enjoys, together with a daily record of who takes part and the benefits to the resident. All staff are involved in the daily activities and take responsibility for filling in this record and keeping it up to date. The visiting community professional interviewed highlighted social activities as one of the main improvements she had witnessed at the home over recent months. A weekly activities programme is in place and this is posted in the communal areas. The inspector recommended that this be reviewed and put into a format which residents with dementia can understand. In addition to regular activities there are plans for some special events including Christmas shopping and musical entertainment. On the afternoon of the inspection residents were enjoying ‘sherry and nibbles.’ A significant number of residents at the home prefer one-to-one support with communication and staff have arranged the Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 14 activities accordingly. The inspector recommended that specialist advice on provision of activities and suitable environments for residents with dementia be sought. The staff of Kathryn’s House make a regular donation of £1.50 towards meals and drinks provided to them whilst on duty; this is then added to the resident’s activities fund and put towards extra treats for residents. Residents enjoy the meals at Kathryn’s House. On the day of the inspection the liver and bacon was both tasty and tender and residents made some very complementary remarks. Some residents preferred the alternative baked potato with cheese and salad which one resident described as ‘beautiful…with butter and everything.’ Another said ‘…yes…the food is lovely.’ This was followed by homemade apple crumble and custard, also popular with residents. Mealtimes are arranged over two sittings with the second sitting reserved for those who either need assistance or prefer to take longer. The mealtime experience for some residents could be improved upon with particular attention to the residents who have dementia. For example, staff were observed to be standing up when supporting residents to eat, and there were not enough staff in the dining room to help all the residents who needed assistance. Another resident’s meal had been left on the table before they had even arrived and this would have gone cold. All suggestions were well received by the manager and owner and they have agreed to explore taking specialist advice on mealtimes. The cook was knowledgeable on the special diets required and those who needed pureed food had this done in a way that preserved the colour of the individual food items and made the meal look appetising. The kitchen was inspected and appeared to be generally clean and tidy. The fridge and food temperatures were regularly kept and within suitable limits. Some issues requiring attention are discussed in the last section of this report. Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Residents can be confident that complaints and adult protection matters are taken seriously at this home, and dealt with according to the proper procedures. EVIDENCE: The complaints book, unavailable at the last inspection has been located and revised to provide a better way of logging complaints. Two complaints have been received in the last 12 months, both dealt with using the complaints procedure and the outcome documented. No complaints have been received since the previous inspection. The complaints procedure is now displayed in a bigger font which makes it easier to read. The owner was asked to consider a format more accessible to residents with dementia. Staff have all recently received training in the protection of vulnerable adults and the inspector examined information on the course content to confirm it contained sufficient reference to the local Surrey procedures. The latest version of the local procedures is now available in the home. There have been no adult protection matters raised since the previous inspection. Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 16 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 and 20. Residents live in a safe and well-maintained environment and have access to safe and comfortable indoor facilities. Further work needs to be done to the outdoor facilities to enable the home to meet this standard in full. EVIDENCE: The owners and staff of Kathryn’s House work hard to provide a wellmaintained and homely environment for residents. Refurbishments since the last inspection include new carpets and curtains in the lounge and other floor coverings in toilets and the dining room. The dining room also has new curtains and tablecloths. The remaining radiator covers have been fitted and these, like the others already fitted, are of particularly good quality, enhancing the look of all the areas where these are sited. A list of completed and outstanding works is kept, but there are no dates by which each outstanding item will be completed. In order to comply fully with this standard, the ‘programme’ of maintenance must contain dates and priorities. Priority should be given to the outstanding requirements from the environmental health department’s inspection in February. The inspector also asked the owners to urgently review the staff toilet facilities which need a thorough refurbishment due to cracked tiles, stained and damaged floor Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 17 covering, the age of the fittings, and general wear and tear. The dining room skirting has been damaged during the recent replacement of the floor covering and the owner said the dining room was going to be decorated following the fitting of the new floor. In the meantime the walls and skirting in the dining area detract from the otherwise homely appearance. The outdoor space at Kathryn’s House, currently used by staff and residents, needs to be reviewed. As there is no garden as such, the outdoor area with covered seating area is the only outdoor space for residents. To comply with this standard it should be tidy, safe, attractive and accessible to residents, and allow access to sunlight. The owner said this would be reviewed and refurbished during the winter; specialist advice should also be taken in order to make sure this provides a safe and suitable area for the residents with dementia. Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 18 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 well catered for by the current staff and the home manager and owners promote and fund training for the staff. EVIDENCE: The pre-inspection questionnaire asks homes to include the current staff rota. Both the rota, and the numbers of staff on duty on the day of the inspection were sufficient to meet the needs of residents. One resident told the inspector she liked the staff and ‘they know what you want before you even describe it.’ However, as already mentioned, more staff needed to be in the dining room to assist residents and therefore the deployment of staff, rather than the numbers on duty, may need to be reviewed. The owner was also asked to use the Residential Forum matrix to calculate staff to resident ratios. This standard (27.7) also includes whether there are sufficient staff overall to maintain the home in a clean and hygienic state and free from unpleasant odours. On the day of the inspection the home was fragrant throughout and staff were complimented on the improvements they have made in this regard. More than 50 of the staff at Kathryn’s House will have reached NVQ level 2 or above by December 2005. It was also good to see that, in the rearrangement of the office, many staff training certificates have been nicely framed and displayed. The Requirements made at the last inspection regarding training have all been met and further training, e.g. on incontinence, first aid, dementia, and the safe handling of medication is planned. Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 19 Recruitment procedures are thorough at this home and staff files examined demonstrated a high regard for making sure that potential staff are suitable and pose no risks to vulnerable adults. The inspector discussed the potential use of volunteers at the home and advised that CRB checks and references would still be required – it is for the home, not the volunteer bureau, to demonstrate suitability. Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 20 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): 32,33,35,36,37 and 38. Management and administration at Kathryn’s House is generally good which means residents benefit from being in a well run home. EVIDENCE: The management approach of the home is good. There is an open and positive atmosphere and the new manager and owners communicate a clear sense of direction. The response to the inspection process and to reviewing issues in line with advice is very encouraging. There are a number of ways in which residents views are sought and this includes residents meetings and Regulation 26 visits to the home. The residents meetings have been reviewed and the new manager now runs the meeting, therefore eliciting more responses from residents, perhaps because she knows them well and is very familiar with their communication needs. The home needs to catch up with it’s own annual quality assurance processes in order to meet this standard in full. The manager said this is likely to begin in Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 21 November and the inspector asked if a sample of the questionnaire could be sent to CSCI to keep on file. The residents who need assistance with their day-to-day spending money can be confident that the home manages this well. The inspector went through the procedures with the manager and checked the money held on behalf of certain residents; all was found to be in order. The written policy on this matter needs to be reviewed to make sure it is a ‘local’ policy, i.e. accurately reflects the situation in this home. Staff supervision at the home is now organised so that all care staff get at least 6 formal supervision sessions per year. In addition the home offers ‘group supervision’ in the form of handovers and staff meetings throughout the year. Health and safety management is generally good in the home and all the previous requirements on this matter have been met. These include a recent electrical wiring safety inspection; the remainder of radiator covers being put in place; and all taps being fitted with thermostats. However a number of issues needed attention in the kitchen. A repair to broken tiling and a fresh coat of paint on the ceiling were waiting to be done. Also, a few items in the fridge were not labelled with dates and this needs to be rectified. A recent unannounced environmental health officer’s report had also highlighted this as an issue. It also required additional hazard analysis topics to be covered and further attention to cleaning some parts of the kitchen. The report noted that some shelves in the storeroom were buckled and due for replacement back in February and this had still not been done. In view of the age and type of decoration in the kitchen area (e.g. tiled walls) the CSCI inspector recommended that the owner consider using specialist contract cleaners for deep cleaning in this area. The refurbishment and safety of the outdoor areas has been mentioned earlier in the report, as has the necessity to carry out a risk assessment where residents administer their own medication. Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 22 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 X 3 3 X 2 Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 23 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 OP7 Regulation 15(1) Requirement The updating of care plans must continue until all residents have a current, complete and regularly reviewed plan The home must arrange to have two inspections from the visiting community pharmacist per year. Residents who self-administer medication must always have a risk assessment in place. The home should review the mealtime experience of those residents requiring assistance, as detailed in the report. The maintenance and renewal programme for the home must contain dates and priorities. The outdoor area must be refurbished to provide safe, accessible and pleasant surroundings where residents enjoy fresh air and sunshine. The home must begin its annual quality assurance audit and send a copy of the questionnaire, intended for residents and stakeholders, to CSCI in advance. Timescale for action 06/01/06 2. 3. 4. OP9 OP9 OP15 13(2) 13(2) 12(1) 16(2)(i) 23(2)(b) 23(2)(b) (o) 13/10/05 07/10/05 13/10/05 5. 6. OP19 OP20 06/11/05 06/02/06 7. OP33 24(1)(3) 06/12/05 Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 24 8. OP38 23(2)(b) 16(2)(j) The minor repairs to the kitchen identified by the CSCI inspector, and the requirements made by the environmental health inspector in February 2005, should be carried out as soon as possible. 06/11/05 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 to improve the mealtime experience for those residents with dementia. The home should consider taking specialist advice on the environment, especially the outdoor area, before updating/refurbishing the home further. The home should use the Residential Forum matrix to calculate staff to resident ratios. 2. 3. 4. OP15 OP19 OP27 Kathryn`s House DS0000013687.V256478.R01.S.doc Version 5.0 Page 25 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.V256478.R01.S.doc Version 5.0 Page 26 - 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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