Inspection on 15/11/05 for Kearsney Manor Nursing Home

This inspection was carried out on 15th November 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

Kearsney Manor Nursing Home 10/04/07

Kearsney Manor Nursing Home 02/08/05

Kearsney Manor Nursing Home 10/03/05

Kearsney Manor Nursing Home 12/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Kearsney Manor Nursing Home Kearsney Manor Alkham Road Kearsney Dover Kent CT16 3EQ Lead Inspector June Davies & Christine Randall Announced Inspection 15th November 2005 09:40 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 Kearsney Manor Nursing Home DS0000026102.V257819.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. Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kearsney Manor Nursing Home Address Kearsney Manor Alkham Road Kearsney Dover Kent CT16 3EQ 01304 822135 01304 829232 kmnh@btconnect.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sisters of the Christian Retreat Mrs Karen Jane Wilczek Care Home 44 Category(ies) of Old age, not falling within any other category registration, with number (44), Terminally ill (4) of places Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. A Nursing bed registered for one (1) person under the age of 65. Of the 44 beds 41 are registered for nursing patients and 3 beds are registered to provide personal care 2nd August 2005 Date of last inspection Brief Description of the Service: Kearsney Manor Nursing Home is a large traditional stone building that has been extended; it is surrounded by extensive landscaped gardens, with a lake and established trees in addition there is a well tended vegetable garden, that produces fresh seasonal vegetables for the home’s kitchen. The home provides residential care for 3 older people and 41 nursing care beds, four of these beds are also registered to provide palliative care. The nursing home is close to Kearsney train station and buses run along the main road, a bus stop is situated close to the home. Pedestrians must take care, as the main entrance to Kearsney Manor is situated on the busy Alkham Valley Road. Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection to Kearsney Manor Nursing Home, carried out by two inspectors over a period of seven hours. The inspectors were able to gain information from talking to residents, relatives, visitors, and staff working in the home, additional information was taken from records kept within the home and from a tour of the building and observation. What the service does well: What has improved since the last inspection? What they could do better: Staff employed in the kitchen; need to have an intermediate food hygiene certificate. The registered manager needs to expand on her quality assurance surveys to include relatives, visitors, visiting professionals and staff. Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 6 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. Kearsney Manor Nursing Home DS0000026102.V257819.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 Kearsney Manor Nursing Home DS0000026102.V257819.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 and 2 All prospective residents, relatives and visitors are provided with a Statement of Purpose and Service User Guide, giving comprehensive information on all aspects of care, and services provided within the nursing home. Each resident is given a statement of terms and conditions/contract, which contains all the information required by the National Minimum Standards. EVIDENCE: The inspector was able to view the Statement of Purpose and Service User Guide, which were seen to contain all the information as required by Schedule 1 on the National Minimum Standards. Prospective residents, the relatives and representatives on reading these documents would have a clear explanation of the services offered by the home, the accommodation provided, an up to date staffing list with staffing qualifications, the number of beds provided by the home, and what level of nursing care, including special needs are catered for. The inspector viewed three statements of terms and conditions/contracts. Each resident is provided with a statement of terms and conditions/contract, which clearly states what services are catered for within the fee being charged Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 9 and the number of the room which the resident will occupy. There is a clear explanation of additional services on offer, for which an extra payment will be required, also included are the rights and obligation of the resident and provider, and the terms and conditions of occupancy. A new resident will be provided with two copies of the statement of terms of conditions/contract, each copy needs to be signed by the resident or their representative, and one returned to the office. Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 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, 10 and 11 The care planning system is clear and consistent and provides staff with the information they need to meet the residents’ needs. The health needs of the residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication at this home is well managed promoting good health. EVIDENCE: The inspector looked at four residents care plans, which gave detailed account of the physical, social care needs and specialised nursing care required by the residents. Each care plan contained detailed risk assessments to ensure that nursing and care staff limit the degree of risk to the resident. Evidence was available to show that the care plans are reviewed each month, and signed by resident or representative. There was no evidence of what personal care tasks had been carried out on daily basis for each resident but personal care was cross referenced to the assessed needs of each individual resident. The inspector was able to speak with six residents and six visitors who all confirmed that the standard of care and cleanliness in the home were of a high standard. Resident comments received were “I think it is good here staff are very caring”, “I am quite happy here, staff treat me with respect”. Visitors Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 11 comments were “I think this is an excellent place, we cannot fault it”, “I have no complaints at all care is excellent any problems and we are kept informed”. None of the residents in the home are self-medicating. The inspector observed the administration of medication during the lunch time period, and witnessed that MAR sheets were appropriately signed off after the medication had been given to each resident. On inspection of the medication rooms evidence was available to show that all medication is correctly recorded on to MAR sheet and checked in by two registered nurses. Controlled drugs are appropriately recorded into a controlled drugs book and signed by two registered nurses when administered. Controlled drugs also tallied with numbers recorded in the controlled drugs book. The drugs fridge was seen to be clean and well ordered, with daily recording of temperatures. Medication no longer used is placed into POM kits and locked is a specially allocated cupboard in the medication room. Returned medication was listed in a returned medication book and signed by two registered nurses. Three oxygen cylinders were stored in the medication cupboard with compressed gas and flammable gas signs placed on the medication door. Residents told the inspector that they are always treated with respect, and that all staff have respect for their privacy and dignity when carrying out personal care tasks. The inspector witnessed while looking at care plans that information was available in relation to the wishes of the resident, for death and dying in regard to specific wishes and funeral arrangements. The registered manager and staff confirmed that staff would sit with residents if necessary when they are dying. The Roman Catholic sisters would visit the dying resident but not as a religious visitor. A priest or vicar from the resident’s own religious belief would be called upon to visit if this was the resident’s wish. If families wished to be with the resident a lounge not often used by other residents or visitors would be made available exclusively for the family, this lounge has microwave, refrigerator and kettle for visitors use, and food and drink could be offered by the home if requested. Families would be able to help with the care of a dying resident if this was the residents wish, staff would be available to answer any questions that may arise. Three registered nurses have all taken part in palliative care training. Kearsney Manor also has very good working relationship with local hospices, and general practitioners will make referrals to Macmillan nurses if necessary. The policy and procedure for death and dying were made available to the inspector, this policy and procedure was detailed and had been recently reviewed. Kearsney Manor Nursing Home DS0000026102.V257819.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 and 15 Activities and community links are good and support the residents’ social opportunities. The meals in the home are good offering both choice and variety and catering for special diets. EVIDENCE: The inspector during discussion with six residents, was told that the activities programme in the home was good, examples of activities taking place were; making Christmas cards, bingo, card games, quiz games, baking sausage rolls, jam tarts etc. Some residents had chosen to go on a trip to Folkestone accompanied by members of staff. Evidence was also available to show that the home employs a part-time activities co-ordinator. Residents are given the choice of being involved in the activities in the home and for some just watching the wildlife from their bedroom window is sufficient. It was noted by the inspector that feeders are placed in strategic positions to enable the residents to watch wild birds and squirrels feeding. During the day of the inspection the inspectors witnessed that visitors were free to visit the home, and this is backed up by the visiting policy and procedure, which is available in the main entrance hall. Where visitors wish to visit later in the evening they are asked to telephone the home first so that staff know they will be visiting. Nine residents are able to manage their own financial affairs with help from a close relative, while other residents have a power of attorney, who manages Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 13 finances on their behalf. The home has a policy and procedure relating to access of personal records and this is written in accordance with the Data Protection Act 1998. The inspector was able to observe the lunchtime meal being served on the day of the inspection. The residents had been given choice of menu, and all meals were nicely presented and served. There were sufficient staff on duty to serve the meal to the residents and to ensure that those residents who needed help with eating were given one to one attention. The inspectors were given the latest updated copies of menus, and these showed a good balanced variety of meals being offered to the residents. The home caters for 2 vegetarian residents, 1 gluten free resident, and 15 meals are pureed with each food item being pureed separately. Kearsney Manor has its own vegetable garden, and fresh seasonal vegetables are grown for year round use. The home has a current clean food award certificate issued by the Environmental Health officer. Kearsney Manor Nursing Home DS0000026102.V257819.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, 17, and 18 Residents and visitors know their complaints will be listened to and acted on. Staff have knowledge and understanding of adult protection issues, which protects the residents from abuse. EVIDENCE: The inspector was able to view the suggestions, concerns and complaints book, which is kept in the main entrance hall. There have been no recent complaints, but it was noted both residents and visitors have made suggestions, and these have been actioned by the registered manager. None of the residents or visitors spoken to on the day of the inspection had any complaints about the home. Evidence was available to show that in the past where a complaint has been made this has been appropriately investigated, acted upon, and a timely reply given to the complainant by the registered manager. The residents have their legal rights protected. Some residents choose to use postal voting facility, while other residents choose not to vote at all. The home has useful information leaflets available for both residents and visitors in relation to advocacy services, which are available in the main entrance hall. The inspector was able to view the homes own policy and procedures in relation to adult protection, and whistle blowing. The home also has the most recent copy of Kent County Council’s, protection of vulnerable adults guidelines. The deputy manager is a qualified trainer and runs in-house POVA training sessions for staff, and this can be evidenced on the staff-training matrix, which is displayed outside the registered manager’s office. To date Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 15 thirty-one members of staff have received POVA and whistle blowing training in-house, this includes registered nurses and care staff. Kearsney Manor Nursing Home DS0000026102.V257819.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, 20, 21, 22, 23, 24, 25 and 26 The standard of the environment both internally and externally is good providing the residents with an attractive and homely place to live. There is an annual maintenance programme to ensure the home is kept in a good state of decoration and repair. Laundry facilities are excellent, with detailed care being given to the residents’ personal clothing. EVIDENCE: The home has a programme of routine maintenance, renewal and decoration. Letters are available to show that the home complies with the requirements of the fire safety officer and the environmental health officer. The home does not use a CCTV system. The inspector was able to tour the building looking at all areas of the home. The home has five lounge/dining areas which residents are able to use, all are suitably furnished and decorated in a homely domestic style, and are used for residents’ activities, dining, and church services. All lounge/dining areas are smoke free. Kearsney Manor has extensive grounds, with mature trees, a large lake (at present the lake is empty and this has caused great disappointment to the residents) usually stocked with trout, duck, swans, and other varieties of wildlife. There is access round the grounds via footpaths and ramps, with a variety of seating for residents use. The grounds Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 17 are well tended and maintained. The inspector witnessed that bathrooms and toilets on the first and second floors had recently been totally refurbished with new sinks, toilets, and domestic style tiling, lighting and flooring, there are sufficient toilets and bathrooms to meet the requirements of the residents, and some bathrooms are fitted with overhead hoists to facilitate bathing for very frail residents. Sixteen bedrooms in the home have en suite facilities. Both first and second floor has its own sluicing room, which is entirely separate from residents’ bathrooms and toilets. The home has suitable disability aids throughout in the form of sling and standing hoists, overhead hoists in some bathrooms, grab rails and elevated toilet seats, hand rails in corridors, walk in/sit shower room and a recently newly fitted shaft lift, which serves all three floors. All communal rooms are easily accessible for wheelchair users. The home has a very large loft area, which can be accessed via a staircase. Part of this loft area is used for the storage of mobility, and nursing equipment. All rooms throughout the building have a call bell system, which is easily accessible for the residents. The home has 36 single rooms and 4 double bedrooms. Double bedrooms have curtains around the beds to maintain privacy and dignity. Each bedroom is well furnished and the inspector witnessed that many of the residents had chosen to bring in small items of their own furniture, all rooms have over bed lighting and ceiling lighting which is domestic in style. Bedroom doors are lockable and residents have the choice of whether they wish to retain their own bedroom door key. The bedrooms are all naturally ventilated, all rooms are centrally heated and radiators have covers in situ. Emergency lighting is provided throughout the building. All water tanks are checked six monthly, and little used water outlets are flushed through weekly to prevent the risk of Legionella. Water temperatures from hot water outlets are checked on a monthly basis to ensure they deliver water at 43°C. On the day of the inspection the premises was clean and hygienic, and free from offensive odours. Universal hand washing posters are placed in communal hand washing facilities, and the inspector noted that bathrooms had sufficient supplies of plastic aprons and vinyl gloves for staff use. The laundry is situated away from the main home in the basement of the convent. The laundry facilities are immaculately clean, with washing machines complying with the standard required. Laundering and ironing is carried out to a very high standard. Kearsney Manor Nursing Home DS0000026102.V257819.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 Staff morale is high, and residents are offered a high standard of care. Recruitment practices are excellent with all appropriate POVA checks and mandatory training being carried out, which creates safety for the residents in the home. EVIDENCE: The inspector was able to view the staff rotas, and these clearly showed that the home has sufficient staff on duty throughout each shift to meet the assessed needs of the residents at all times. The registered manager has also been able to build up a register of bank staff, who can cover for sickness and annual leave at short notice; this has alleviated the need to use agency staff. The inspector was able to witness that the rota complied with the numbers of staff on duty. There was also evidence on the day of the inspection that there was a sufficient skill mix of staff on duty to meet the assessed needs of the residents. The inspector was able to speak with eight members of staff, all said that at the present time there were sufficient staff on duty, the registered nurses said that sometimes the workload gets heavy and this can put pressure on the team. At the present time the home has 51.8 of its care staff having achieved or about to achieve (just awaiting internal verification) NVQ level 2 or 3. Three members of care staff are also student nurses. The inspector was able to view three personnel files at random. These files were excellently presented, with a checklist in the front of each file, to ensure paperwork was available within the file. Each file looked at showed that a POVA first check, and CRB had been applied for, all files had two written references, with one of those two references being from the previous Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 19 employer. All staff with the exception of the newest member of staff has a contract of employment and all staff are issued with a GSCC code of conduct on their first day of employment. Each file contained training certificates, and there was evidence that staff induction takes place in accordance with TOPSS induction standards. The training matrix is displayed on the wall outside the registered managers office, and this showed that the majority of staff had received mandatory training, with mop up sessions for new staff and staff who need to renew their training being planned for in the near future. There was also evidence of other work related training taking place both for the registered nurses and care staff, and that up take on these training sessions were good. The inspector spoke to eight members of staff, all said that staff morale was good, the registered manager was very fair, that the home provided them with good training, and that the whole team were helpful to one another. All staff said that they were happy working at Kearsney Manor. Kearsney Manor Nursing Home DS0000026102.V257819.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): 31, 32, 33, 34, 35, 36 and 38 The registered manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. Residents benefit from a well run and safe environment. EVIDENCE: The registered manager is qualified, competent and experienced to run the home, she is a qualified nurse, with a degree and has attained the NVQ level 4 and RMA this year. The registered manager makes sure that she visits the residents on a daily basis when on duty, and is always available for members of staff. Residents, visitors and staff spoke very highly of the manager and her managerial skills. The registered manager has a job description, which enables her to take responsibility for the daily management of the home, and she is very aware of her lines of accountability with the trustees of the home. Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 21 During her tour of the building the manager is also available to staff, and when working in her office she operates an open door policy, for residents, staff, relatives, visitors to the home. Everybody connected with the home has the opportunity to put forward suggestions for improvement to the manager. The inspector was able to talk to several staff on duty on the day of the inspection, and all said that they found the registered manager to firm and fair. Residents in the home said that they would be able to approach the manager with any concerns they had. Relatives spoken to by the inspectors said that they were kept well informed of any changes to their residents, and that the manager would listen to any concerns they had. The registered manager has developed a quality assurance questionnaire for the residents in the home. Some of the residents in the home are very frail and in this case the resident’s next of kin often completes the questionnaires. From these questionnaires the registered manager has developed a comprehensive feed back sheet, which is displayed in the main entrance hall. The home has an annual development plan, which highlights areas of improvement both within the environment of the home and the development of quality care for the residents within the forthcoming year. Some discussion took place as to how the quality assurance questionnaires could be extended to relatives, visiting professionals and staff who work in the home, to ensure that an overall picture of the quality of care in the home can be achieved. The inspector was able to view the policies and procedures file and this showed that all have been reviewed in this year. The home has an annual budget system, and this shows that the home is viable, and is able to plan ahead for projects in the coming years. There is a comprehensive insurance policy, which was seen to be current. Some residents and their relatives have requested that the home looks after personal allowances, where this is the case each resident has their own accounts sheet, and receipts are attached and entered of any expenditure taking place, monies given to the home for the residents use is also entered onto the sheet. The registered manager is not an agent for any of the residents’; all pensions are paid directly into resident’s personal bank accounts. All personal monies looked after by the home, is kept securely in the finance office safe. When resident requests that personal possessions are kept by the home for safekeeping, an inventory is raised and the personal possessions are kept securely in the safe. All staff in the home receive one to one supervision at least six times per year, both staff and the registered manager report that they have found supervision to be a very positive exercise. The registered manager places high priority on the health and safety of the residents and staff in the home. Every room and piece of equipment has been risk assessed and these risk assessments are reviewed on a regular basis. All relevant health and safety signs are displayed in appropriate places throughout the home. There was a recently reviewed health and safety policy in the policies and procedures file. The inspector noted that appropriate contractors had maintained all equipment within the home within the last year. Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 22 Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 23 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 3 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 4 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 3 18 3 3 3 3 3 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 x 3 Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP30 OP33 Good Practice Recommendations Cooks employed by the home should hold an intermediate food hygiene certificate. The views of family and friends and of stakeholders in the community (e.g. GPs, chiropodist, voluntary organisation, staff) are sought on how the home is achieving goals for the residents. Kearsney Manor Nursing Home DS0000026102.V257819.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Kearsney Manor Nursing Home DS0000026102.V257819.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!