Inspection on 09/07/08 for Keep Hill Rest Home

This inspection was carried out on 9th July 2008.

CSCI found this care home to be providing an Good service.

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

Keep Hill Rest Home 20/07/07

Keep Hill Rest Home 30/08/06

Keep Hill Rest Home 07/02/06

Keep Hill Rest Home 14/12/04

Keep Hill Rest Home 16/06/04

Similar services:

St Vincents

The Cotswold Home

Winton House

Newbeech House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Keep Hill Rest Home 17 Keep Hill Drive High Wycombe Bucks HP11 1DU Lead Inspector Joan Browne Unannounced Inspection 9th July 2008 11:00 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 Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 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. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Keep Hill Rest Home Address 17 Keep Hill Drive High Wycombe Bucks HP11 1DU 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) 01494 528627 N/A keep.hill@tiscali.co.uk N/A Mr Grahame Robinson Mrs Gillian Robinson Grahame James Robinson Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2007 Brief Description of the Service: Keep Hill Rest Home is a care home registered to provide care and accommodation to nine older people. It is privately owned and is located in a residential area on the edge of High Wycombe, close to local amenities, shopping and public transport. The home was originally a semi-detached, double fronted house, which has been extended to accommodate nine residents. All bedrooms are single and two are fitted with en-suite facilities. Other bedrooms are close to bathrooms and toilets. There are a limited number of car parking spaces at the front and a compact, but accessible, garden with a patio area and pergola at the rear of the home. The range of fees at the time of this inspection were £420.00-£450.00 per week. Information about the home can be obtained by contacting the home. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced site visit, which forms part of the key inspection to be undertaken by the Commission for Social Care Inspection, (CSCI) was undertaken by Joan Browne on the 9 July 2008 and lasted for seven hours. Commencing at 11:00 hours and concluding at 18:00 hours. The CSCI Inspecting for Better Lives (IBL) involves an Annual Quality Assurance Assessment (AQAA) to be completed by the service. This document, which includes information from a variety of sources, was received in good time. This initially helps us to prioritise the order of the inspection and identify areas that require more attention during the inspection process. This document is referred to throughout the report. The manager and the care manager were in attendance throughout the visit. The majority of the residents spoken to were able to express their thoughts and feelings about the care they receive. The information contained in this report was gathered from observation, a tour of the premises, by speaking with residents, two relatives and with care staff. Further information was gathered from records kept at the home and surveys from people using the service. All residents in this home are Caucasian and reflect the population of the area in which the home is situated. All records sampled were mostly up to date. One requirement and six recommendations of good practice were issued on this visit. Please see Health and personal care outcomes, Staffing Outcomes and Management and Administration outcomes for full disclosure. The final part of the inspection was spent giving feedback to the manager and care manager about the findings of this visit. The inspector would like to thank all the residents and care staff that made the visit so productive and pleasant on the day. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Care plans should be signed by people using the service whenever capable or their representatives to indicate their involvement and agreement in the development of the plans. Regular monitoring of staff’s competencies in the safe handling, recording and administration of medication should be carried out and recorded to ensure compliance. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 7 Medication administration record sheets should be regularly audited and recorded to ensure compliance. The home must ensure that staff who have previously worked with children or vulnerable adults record the reason for leaving on their application form. The names of staff that participate in fire drills should be listed in the fire record to comply with best practice guidance. 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. The summary of this inspection report can be made available in other formats on request. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 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 Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that prospective people to use the service diverse needs are assessed prior to admission. EVIDENCE: Prospective people get to hear of the home through word of mouth or via health care or social services professionals. Review of a random sample of residents’ files including the two recently admitted residents to the home, demonstrated that pre admission assessments were carried out. We were told that the care manager undertakes the assessment process and visits individuals in their homes or hospital. If it is felt that the home can meet the person’s needs then an offer of a place is made. The person or their family may visit the home to view the facilities as part of the assessment process. Two residents confirmed that a relative had visited the home to look around. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 10 One resident commented that she was so pleased with the facilities when she came to look around that she requested to be admitted immediately and her request was granted. A trial admission of four weeks is offered to allow both parties the opportunity to consider whether the home can meet the assessed needs. A review with the resident, their family and social worker is held at the end of the trial period. The home does not provide intermediate care. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has a good and clear care plan in place with appropriate risks assessments, which should ensure that people’s health and personal care needs are met appropriately. Some medication practice needs reviewing to ensure individuals’ safety and welfare are promoted. EVIDENCE: The randomly selected care plans were clear and easy to read with actual risks to residents identified and documented with supporting evidence detailing how these risks would be managed. We observed that the care plans were reviewed monthly. However, the resident or their relative did not sign the care plan to indicate their involvement in deciding what care they received. Not all the care plans seen were signed by a staff member. A recommendation is made for the care plans to be signed by the residents whenever capable or their representatives to indicate their involvement as well as the staff member. In addition to the care plans detailed guidance notes were in place outlining how individuals wished to be supported by staff with their night and morning Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 12 routines. Progress on individuals’ daily routine and personal care provided was recorded in the daily log. Evidence was seen that individuals’ weights were maintained and recorded on a table graph monthly. All residents were registered with a local general practitioner (GP). We were told that residents could retain registration with their own GP providing the home was within the catchment area of the surgery. A chiropodist visits every six weeks for which an additional charge is made. An optician visits the home by arrangement. Dental services are accessed through a local dentist in the area. We were told that the home has a good relationship with the local district nurses who visit the home as and when required. People requiring continence aids and equipment are assessed and the appropriate aids and equipment are provided. Other national health services such as the dietician, occupational therapy, and physiotherapy are accessed via the GP. Residents looked generally well cared for and those who responded to the Commission’s survey expressed satisfaction with the care provided. The medication administration record (MAR) sheets were examined and no unexplained gaps were noted. However, on the MAR sheet for a specific resident tippex correcting liquid was used. Scribbled over entries were also noted on some sheets examined. Because the MAR sheet can be used in evidence before a court of law or in a complaints investigation it is recommended that staff should not use tippex correcting liquid and scribble out entries on the MAR sheets. We were told on the day of the visit that one resident was risked assess as capable to self medicate. The AQAA reflected that yearly medication audits by the home’s pharmacist are carried out. The most recent audit report was made available for the inspection purpose and was satisfactory. We were told that training for staff in the safe handling, recording and administration of medication is facilitated by the care manager and that their competencies are regularly assessed. However, there was no written record of staff’s competency assessments. It is recommended that records are maintained for inspection purposes. We observed all medicines were stored in a lockable drug cupboard. Medicines are temporarily transferred and stored in a portable box for administration and taken downstairs for administration to the residents. If an emergency happens while medicines are being administered we were told that staff had been directed to lock the box in the utility room on the ground floor. We observed that a bottle of lactulose for a particular resident was left in the bedroom on a shelf. This practice should be reviewed to ensure that it is stored in a lockable storage cupboard in the room. We also observed that a staff record for administration of homely medication such as paracetamol was being maintained. There was no medication in stock but the record reflected that in February 2008 a staff member was in receipt of two paractemol tablets. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 13 This practice should be reviewed as it is not advisable that the home should be responsible for staff to have access to pain killers in case they may have an adverse reaction. We observed that care staff wore name badges to enable residents and visitors to be sure of whom they are speaking with. We also observed residents being treated in a friendly but respectful manner by care workers. In discussion with residents they told us that they are treated with respect and dignity, and that they are able to make their own choice. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home ensures that people are provided with a range of activities to meet their diverse needs. Wholesome meals are provided in pleasing surroundings. EVIDENCE: Wherever possible the home aims to accommodate individuals’ choices. Residents’ equality and diversity needs are met in terms of their age, gender disability and religion. Information reflected in the home’s annual quality assurance assessment (AQAA) stated that residents’ interests and preferences on activities are recorded in their activity plans. Those residents spoken to said that they choose to participate in activities if they wished to or remain in their bedrooms. The manager said that the range of activities had increased since the last inspection. These included quizzes, board games, crosswords, pets as therapy, trips to garden centres, trips to the local library, theatre, singalong, bible study and exercise to music. The manager has undertaken an activity-training course and is responsible for facilitating the daily activities. The following comments were noted from residents who responded to the Commission’s survey: “I feel the physical activities benefit me and I enjoy Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 15 taking part and helping where I can.” “I enjoy the activities. I feel they do me good and I enjoy dong things with other people.” The home’s annual quality assurance assessment (AQAA) stated that within the last twelve months more activity equipment had been purchased. On the day of the inspection visit no activities were facilitated however, two residents were out at a local day centre, which they attend weekly. We observed that there was a two-week activity programme in place. We noted that the home had acted on comments made by respondents to the Commission’s survey at the previous key inspection and had provided a television in the lounge. The religious needs of residents are respected and promoted. The home was in contact with the local Baptist church and Sunday services are organised. Residents spoken to at the time of the site visited confirmed that the home celebrates their birthdays and a birthday card, present and cake are provided. Residents may have visitors at anytime within reason. We spoke to two relatives that were visiting during the inspection. They confirmed that they were able to visit at anytime and the home’s staff and managers always made them feel welcome and provided them with refreshments. They were also very pleased with the provision of care and said that the home was kept clean and pleasant. One visitor said that ‘their relative general health had improved since coming to live in the home.’ On the day of the inspection there were no residents using the services of an advocate. Residents are made aware that they are entitled to bring personal possessions with them if they wish to. Some bedrooms seen were personalised with residents own furniture and family pictures. The annual quality assurance assessment (AQAA) stated that ‘residents are provided with flexible meal plans with changing menu and alternative meal choices.’ We observed lunch being served. The dining room table was covered with an attractive tablecloth and the appropriate cutlery and condiments provided. Residents were offered a choice of orange or blackcurrant drink. Lunch consisted of tomato soup, followed by fish pie, cauliflower, brussel sprouts and carrots. Followed by prunes and custard for dessert. A vegetarian alternative was provided for one resident. Residents spoken to said that the food was very good and plentiful. The following comments were noted from those residents who responded to the Commission’s survey: “Quite content with the meals. They always give a choice but I prefer to eat what is going, as this is how I was brought up. So not all meals are necessarily my favourite.” “Some of the girls are very good cooks. Choice is good and the variety is adequate for me.” “They always cater for my vegetarian needs.” Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The home has a satisfactory complaints policy and safeguarding of vulnerable adult policy in place to ensure that people are listened to and they are protected from any potential harm or abuse. EVIDENCE: The home has a complaints procedure and a copy of it was displayed on the wall. A record is kept of all complaints made and includes details of investigation and any action taken. A folder is maintained for compliments received and there were several complimentary notes in the folder. Information recorded in the annual quality assurance assessment (AQAA) stated that within the last twelve months the home had received one complaint but there was no record of the complaint recorded in the complaints folder. This was discussed with the manager during the inspection who said that the information was recorded in error. The Commission has received no complaints about the service since the last inspection. Residents spoken to during the inspection and those who responded to the Commission’s survey said that they were aware how to make a complaint and who to speak to. We were told that all residents were on the electoral register and they usually have a postal or proxy vote. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 17 The home has safeguarding of vulnerable adults and whistle blowing policies in place. Staff receive training on the safeguarding of vulnerable adults on induction and undertake periodic updates. At the previous inspection a requirement was made for the home’s policy to be reviewed to ensure that it conform to the Buckinghamshire joint agency policy. It is pleasing to report that the requirement had been complied with. Evidence was seen verifying that Bucks County Council audited the policy. Staff spoken to were aware of the action that should be taken if they witnessed or suspected a resident was being abused. Staff records examined indicated that staff had undertaken training in the safeguarding of vulnerable adults at induction. Residents spoken to said that they felt safe living in the home. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People live in a home that is able to meet their diverse needs because the environment is safe, clean, and comfortable. EVIDENCE: The home is situated in a quiet residential area of High Wycombe. It is situated on two floors. The ground floor accommodation comprise of five bedrooms, two toilets and two showers, dining area, lounge and utility room. The first floor includes the office, four bedrooms, one toilet and shower area and a storeroom. There is a garden situated to the rear of the premises, which is well maintained. We were told that the building was recently inspected by the local fire service and all fire related matters were found to be satisfactory. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 19 The home’s annual quality assurance assessment (AQAA) reflected that improvements to the environment and fabric of the home had been made and further improvements within the next twelve months were to be carried out. A tour of the building demonstrated that the lounge and dining area had been re-painted. Handrails had been fitted in all corridors. Restrictor valves had been fitted to showers and sinks in residents’ bedrooms and radiators were fitted with guards. However, one resident requested not to have a guard fitted to her radiator and the request was granted. The appropriate risk assessment was in place and the manager said that it would be kept under review. Floor coverings in the lounge and dining room had been replaced. We were told the management and staff encourage residents to see the home as their own home. On the day of the inspection the home was clean, tidy with no offensive odours. The laundry room was situated away from where food was stored and prepared and the walls and floor were satisfactorily maintained. We noted that the home had introduced colour coded laundry bags to comply with good infection control practice. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. There has been an improvement in the staffing numbers during the daytime to ensure that people living in the home are fully supported and their safety is promoted. EVIDENCE: The home has reviewed the staffing rota and there are now two staff members on duty during the waking day seven days a week. However, there is still one staff covering the night shift with a manager on call. The manager said that he had risk assessed the dependency levels of the residents and the staffing provided was adequate to meet their assessed needs. The annual quality assurance assessment (AQAA) stated that 91 of the care staff had achieved national vocational qualification (NVQ) 2 in direct care. Examination of two staff members’ files recruited since the last inspection demonstrated that they were in receipt of criminal record bureau clearance (CRB) and protection of vulnerable adults (POVA) first checks. Terms and conditions of employment had been issued. It was noted that one of the staff members did not state the reason for leaving on her application form. The individual had previously worked with children. Since 26 July 2004 the Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 21 regulations require that where a person had previously worked in a position, which involved contact with children or vulnerable adults, written verification (so far as reasonably practicable) of the reason why he/she ceased to work in that position should be obtained. A requirement is made on this standard. We were told the home has a programme of planned training in place and all members of staff have an individual training record. In the randomly selected staff’s files reviewed all had completed an induction programme. We observed that the home had a training schedule with training booked up to November 2008 in infection control, dementia, awareness, fire safety awareness, and safeguarding of vulnerable adults. The home has joined with other care homes in the Buckinghamshire area to form a cluster group with the aim of undertaking joint training events for staff working in homes. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People have confidence in the home because managers who are in daily contact run it, which should ensure that individuals’ health, safety and welfare are promoted and protected. EVIDENCE: The registered manager who is also one of the proprietors has been managing the home for sometime. He has acquired the registered manager’s award (RMA). The care manager who is the other proprietor has a background as a medical scientific laboratory officer and has acquired the national vocational qualification (NVQ) 3 in direct care. Staff spoken to said that they felt supported by the management team and residents and relatives spoken to Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 23 during the inspection said that the management approach of the home created an open atmosphere. Evidence of an evaluation system providing an opportunity to improve the service by consultation with residents was seen. The care manager consults with residents individually once a month and they are given the opportunity to raise any issues or concerns, which are acted on. A written record of meetings is maintained. The AQQA stated that as a result of listening to people the home had introduced relatives’ questionnaires for relatives to comment on the quality of the service and a 6 monthly newsletter for residents, relatives and staff had also been introduced. Informal meetings with relatives take place and they are invited to annual care reviews with social workers. The AQAA was returned on time and contained relevant information supporting the claims made. We were told that the home no longer looks after residents’ money. Residents or their relatives are provided with invoices for any expenses incurred for such things as newspapers, hairdressing or chiropody treatment. We were told that supervision records were up to date and this was verified during random sampling of staff’s files. General staff meetings are held every eight weeks but we were told that they are not well attended. There was a detailed fire risk assessment for the building in place that was developed by the manager and the fire officer commended him for providing such a detailed risk assessment. Fire records seen demonstrated that the fire panel record was up to date and weekly checks were taking place. Evidence that staff participate in regular fire drills was seen. However, the home needs to ensure that the names of staff that participate in fire drills are recorded in the fire log. The kitchen was generally in good order and records of food temperatures and refrigerators were being maintained. Information in the annual quality assurance assessment (AQAA) reflected that the servicing and testing of the home’s maintenance equipment was up to date. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 24 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 2 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 25 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. 1. Standard OP29 Regulation 19 Schedule 2 Requirement Staff must record the reason for leaving on their application form especially where the individual had previously worked in a position, which involved contact with children or vulnerable adults. This is to ensure that people using the service are protected from any staff that may not be fit to work with vulnerable people. Timescale for action 31/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP9 OP9 Good Practice Recommendations Care plans should be signed by people using the service whenever capable or their representatives to indicate their involvement as well as the staff member. To comply with best practice guidance staff should not use tippex correcting liquid or scribble over entries on the medication administration record (MAR) sheets. To comply with best practice guidance medication left in DS0000022983.V367543.R01.S.doc Version 5.2 Page 26 Keep Hill Rest Home 4 5 6 OP9 OP9 OP38 people using the service bedrooms should be stored in a locked cupboard. The home should review the practice of keeping a stock of homely medication such as paracetamol for staff because staff could have an adverse reaction. Regular monitoring of staff’s competencies in the safe handling, recording and administration of medication should be carried out and recorded to ensure compliance. To comply with fire regulations the home should ensure that the names of staff that participate in fire drills are listed in the fire record. Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Keep Hill Rest Home DS0000022983.V367543.R01.S.doc Version 5.2 Page 28 - 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. 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