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Inspection on 13/11/06 for Kelstone Court Nursing Home

Also see our care home review for Kelstone Court Nursing Home for more information

This inspection was carried out on 13th November 2006.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

We found good relationships between staff and residents. Residents felt that the majority of staff worked well and had a caring approach. Comments on the staff included "the staff here are very kind", "always helpful" and "very patient". Residents and visitors gave very positive comments on the activities available. Residents told us:- "There are always activities I can take part in", "I have never known a place that provides more activities". Family members said that they were pleased that residents had so many opportunities to go out to places of interest and for meals and drinks. Medication is well managed which assists in promoting the health and welfare of residents. The home owners have made and continue to make improvements to the environment.

What has improved since the last inspection?

Following complaints made regarding the care provided the home owners have taken prompt action to introduce new care planning and monitoring systems. The work required to improve the wound care documentation has already been carried out and a commitment has been made to review all of the care plans in the home within a short period of time. The home owners have taken note of the Office of Fair Trading report on contracts in care homes and made changes to the contracts they provide.

What the care home could do better:

There are a number of areas which could be improved. As noted in previous inspection reports an initial care plan must be in place when anyone is admitted to the home. The care planning documentation needs to address the individual needs and wishes of each resident and give clear information on how these will be met. Residents and or their representatives need to be involved in and agree the care plans. Assessments need to be fully completed and reviewed along with the care plans on a monthly basis. Staff involved in the production of care plans would benefit from training on person centred care planning. Daily recording must be accurate and provide information on the care provided. Staff must not alter notes after the event and must sign and date all documentation. Monitoring of the care, documentation and training has not been adequate. Staff training records need to show that each individual member of staff has been provided with appropriate training and at least three paid days training each year. Staff also need to be provided with regular one to one supervision. Work needs to be done on improving communication between staff, families and other professionals. Staff need to understand the importance of dealing with complaints or concerns in a sympathetic and prompt manner. Residents must be consulted on the meals provided and further work needs to be done on how food is presented, recorded and how meal times are organised.

CARE HOMES FOR OLDER PEOPLE Kelstone Court Nursing Home Cambourne Road Morden Surrey SM4 4JN Lead Inspector Liz O`Reilly Unannounced Inspection 10:00 13 November 2006 to 3 February 2007 th rd 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 Kelstone Court Nursing Home DS0000060496.V318319.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. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kelstone Court Nursing Home Address Cambourne Road Morden Surrey SM4 4JN 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) 020 8542 0748 Yourcare Ltd Sarah Elizabeth Jackson Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: Kelstone Court is a registered care home with nursing providing accommodation and care for up to thirty residents. Twenty places are for older people who require nursing care. Ten places are for older people who require residential care. Accommodation is set over three floors with a passenger lift available for access. The home is a large purpose built property situated in a residential area of Morden in Surrey. The home is close to a group of local shops and a pub with Morden Park and Cannon Hill recreation grounds nearby. Public transport is easily accessed from the home and unrestricted parking is available in the local area. The home is owned by Yourcare Limited. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two regulation inspectors and one regulation manager and consisted of three inspection visits to the home, discussions with residents and staff and meetings with senior staff from the organisation. Questionnaires were provided to a sample of residents, staff, relatives and other professionals involved with the home. During the course of this inspection four complaints were raised with the CSCI. As a result of the concerns raised regarding the care provided the timescale for this inspection was significantly extended. Actions taken as a result of these complaints are also included in this report. Judgements are made using information gathered from all of the above sources. What the service does well: What has improved since the last inspection? Following complaints made regarding the care provided the home owners have taken prompt action to introduce new care planning and monitoring systems. The work required to improve the wound care documentation has already been carried out and a commitment has been made to review all of the care plans in the home within a short period of time. The home owners have taken note of the Office of Fair Trading report on contracts in care homes and made changes to the contracts they provide. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 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 Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including visits to this service. The needs of each person are assessed before they move into the home. To make sure that the full needs and wishes of residents are known and met, staff must use this information to set up the initial care plan. This home does not provide intermediate care. Amendments have been made to the homes contract to comply with good practice. EVIDENCE: Assessments of the individual needs of each person are carried out before they move into the home. Where residents are placed through social services the home receives a copy of the care management assessment. Staff from the home will also carry out their own assessments. In one of the residents files examined it was noted that the care plan was dated fourteen days after their admission to the home. Each person must be provided with an initial care plan at the time of admission taking into account the information provided by the pre admission assessment. This will make sure that staff are aware of some of the basic needs and wishes of the residents in their care. A requirement was made about this issue at the time Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 9 of the last inspection of the home. Following admission staff can then consult with residents and or their representatives to further develop the care plan. The registered persons must make sure that they have confirmed in writing to the resident, that having seen or carried out the assessment the home can meet the needs of the person. During the course of this inspection discussions have taken place with the home owners regarding the residents contract. The home owners have made alterations to the contract in line with the Office of Fair Trading guidelines. Confirmation that residents have been provided with the appropriate information on fees as set out in amended regulations from 1st September 2006 must be provided to the CSCI. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including visits to this service. The care plans at the beginning of this inspection and other records did not give sufficient information to staff to provide adequate care or to evidence that appropriate care has been given to individual residents. Wound care records were inadequate. Medication was seen to be well managed. However the lack of pain assessment for individuals meant that residents were at risk of being left with inadequate pain control. The organisation has now developed new care planning documentation which will be implemented over the next few weeks. The standard of recording must be improved and documents must not be altered. EVIDENCE: The care plans seen focused on the nursing needs of individuals. Staff are using a pre printed system which they had not adapted to meet the needs of individual residents. On one care plan information was in place for an infection and a high temperature. Staff informed the inspector that this person did not have an infection or a high temperature. Information on the care plan stated that a Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 11 fluid balance chart was in place and that this person had a wound. Staff informed the inspector that this was not the case. Information was available on using a hearing aid but no individualised information was in place on how to communicate with this person. Information on supporting individuals to mobilise was basic. Manual handling assessments had not been completed. Instructions were to evaluate the care plans every six weeks. Staff should be reviewing care plans at least monthly or more frequently should there be any changes. Wound care documentation was poor. Care plans setting out how wounds would be treated for individuals were not in place. Pressure sore risk assessments had not been completed. Information on the pressure relieving equipment to be used was not available. Records did not give information on the size of any wound. No information was available on what advice had been provided by the tissue viability nurse where consulted. Wound charts and daily notes gave no information on how frequently dressings should be changed and the records showed large variations in how frequently dressings were renewed. Assessments of pain were inadequate. The lack of evidence to show that wounds had been treated properly has meant that complaints made about the care have been upheld. Feedback from residents and relatives was mixed. The majority of comments indicated that residents were satisfied with the care they receive. However in two instances family members felt that little action had been taken when their relative had been complaining of pain. In another instance it was felt that staff did not take sufficient care in looking after a residents hearing aid and one person felt that staff did not take any action to get a hearing test for their relative. At the time of the last inspection of this home improvements were seen to be being made in the care planning. Since this time a new care planning system has been introduced. It is clear that staff were not familiar with how to use these tools and were attempting to work with both systems. We are of the opinion that this resulted in a disjointed system which failed to provide adequate information for staff on the needs and wishes of individuals or how these were to be met. This left residents at risk. The lack of information on the social, emotional, cultural, religious or sexual needs and wishes of residents is of concern. If residents are to lead as full a life as possible clear information on how they are to be supported as individuals must be in place. We found no evidence that residents and or their representatives had been consulted on their individual care plans. Residents spoken to were unaware that they had a care plan. Staff should be provided with training on person centred care planning. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 12 When making entries in the daily notes staff must put the time of the entry. The use of nocte is not acceptable. Staff must sign and date all documentation and qualified staff must include their qualification with their signature. We found that staff had made alterations to daily notes after the event that were not accurate. Staff must not alter daily notes or records after the event. Should errors be made these can be noted but must not be changed, overwritten or erased. Staff from the CSCI have met with the registered persons from the home and requirements were made for all wound care plans to be reviewed without delay and all care planning in the home to be reviewed over a specified period. The requirement to provide detailed up to date wound care documentation has been met. Staff were unable to meet the timescale for the review of all care plans and it was agreed that this timescale would be extended to 25th March 2007. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The activities organiser provides with a wide range of activities which take into account individual and group needs and wishes. Families are encouraged to maintain contact with their relatives and to be involved in outings. Comments from residents on the food provided indicated that more work needs to be done on consulting with individuals about the menu. More care needs to be taken on how meals are presented. EVIDENCE: Residents made positive comments on the activities available and were observed to join in quizzes and discussions. The preferences of individuals were well known to the activities organiser. There are frequent opportunities for residents to go out. Activities planned for December included carol services, a Christmas party, a meal out at a local pub, Christmas shopping and a trip to see Christmas lights. The home has developed links with a local school. Residents had recently enjoyed listening to and reading war poetry. A number of people said they also enjoyed listening to the activities organiser reading aloud to them. Senior staff impressed as committed to encouraging families and friends to be involved in outings. Further work should be done to encourage nursing and care staff to be involved in activities when the activities worker is not on duty. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 14 A number of residents felt they particularly enjoyed the cooked breakfast but occasionally there were not sufficient eggs or bacon, staff confirmed that this did happen at times. On the day of one visit residents were served fish cooked in breadcrumbs. Some residents were observed to have difficulty in eating the coating and or removing the coating from the fish. Comments received on the food were mixed and included:- “I always enjoy the food here”, “the food is ok”, “mother does not like the meals I provide extra food for her”, “there has been a decline in the meals”, “meals were always perfect but now are not as adequate for somebody with a robust appetite. and “people don’t always get what they asked for”. These comments would suggest that the levels of satisfaction with the food provided have gone down lately. During one visit the meal time was observed to be disorganised and noisy with staff going through the lounge with large boxes from a store room outside and little consideration being given to the experience of residents at the meal time. On a second visit the meal time was better organised. Due to the lack of space, at present residents have no choice but to eat their meals where they sit in the lounge. Meals were seen to be served on trays with no condiments either on the tray or offered. The use of ‘bibs’ should be reviewed. Residents need to be consulted about the menus on a regular basis. Once completed the extension should provide opportunities for meals to be taken at a table. Further work needs to be carried out to review meal times and look at how they can be improved to become a more relaxed social event for residents. The record of food was not up to date. An up to date record of food must be maintained. Evidence that the home meets the cultural and religious needs and wishes of residents in relation to food must be available. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including visits to this service. The response by the home to recent complaints is inadequate. The complainants were not kept informed of actions taken. Requests for staff to contact complainants were not complied with. The manager reported that all staff have received POVA training in 2005. EVIDENCE: The home has a complaints procedure in place. However the manner in which complaints have been dealt with in the past is inadequate. Communication between staff and those making a complaint or bringing to their attention concerns was poor. The registered persons must ensure that all staff are aware of their responsibilities in dealing with complaints or concerns as soon as they are brought to their attention. Complaints need to be viewed as a way to improving the service for residents. All staff must be provided with guidance on dealing with concerns or complaints and on effective communication. Two comments were received on the complaints process, one resident said that they did not know how to make a complaint and a relative said “I do know who to speak to but it makes no difference” All staff must be provided with refresher training on the protection of vulnerable adults within a care home setting. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A number of areas have been refurbished. There are still some parts of the home in need of redecoration and refurbishment, particularly bathrooms. Progress is now being made to complete the extension which will provide much needed extra space for residents. EVIDENCE: The home owners have invested a significant amount of money in redecorating and up grading areas of the home. This work is still in progress with work now resumed on the extension to the ground floor. This will provide additional communal space for residents and offer the opportunity to take meals at a dining table. At present residents have no alternative but to take their meals from their chairs in the lounge which can be quite cramped. Bathrooms, particularly on the ground floor are in need of refurbishment. The manager informed the inspector that plans were in place for this work to be Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 17 done in the near future. New carpeting has been ordered for the lounge and the extension. All areas of the home seen during visits were clean and tidy. Residents felt that there were good standards of cleanliness in the home. The laundry area has recently been upgraded and is furnished with appropriate equipment to meet the needs of the home. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty at any one time to meet the needs of the present resident group. Residents said they had confidence in the staff, however there were times when no one was immediately available to help them. Staff are offered training and a number of care staff have done or are in the process of completing NVQ training. This assists in ensuring residents are supported by a well informed staff team. Further work needs to be done to provide evidence that all staff are provided with at least three paid days training each year. Appropriate checks are carried out on staff before the start work in the home to protect residents. EVIDENCE: Senior staff make sure that there are always sufficient numbers of staff on duty to meet the needs of residents. Staff said they were offered good opportunities for training. The manager stated that six members of staff had or were in the process of completing NVQ training. The qualified staff spoken to said they were given opportunities to attend appropriate training. The record of training did not provide evidence that all staff are provided with at least three paid days training each year. We were informed that the training record was not up to date. A review of the training needs of each member of staff must be carried out. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 19 The majority of residents made positive comments on the staff and their approach. Staff were described as “very nice” and “helpful” and “polite”, two residents felt that they were “looked after very well”. A number of residents made very positive comments about the activities organiser. One area which did come in for criticism from residents and visitors was the time it could take for staff to respond to a request for help particularly for assistance with going to the toilet. We observed one member of staff being asked by a resident for assistance to go to the toilet. This member of staff responded by saying they would be there “in a minute”. The staff member then walked out of the lounge and the resident waited over five minutes for them to return. No explanation or apology was given to the resident for the delay. The senior staff team need to look into how the work is organised and how staff respond to requests from residents. We also observed staff using hoists to assist people without any communication between the staff and the resident. We did also observe good practice by staff in explaining how they were going to help someone with mobility problems and talking them through the procedure while they were helping them. Positive comments were received from visitors to the home about the staff group and how welcome they were made to feel. However one person felt that senior staff in the home and from the organisation were not as communicative or made them feel as welcome as in the past. Staff need to be provided with guidance on communicating with residents and visitors. A sample of staff files were examined and these showed checks have been carried out, including references and Criminal Records Bureau checks, before individuals start working in the home. These checks assist in protecting residents. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including visits to this service. During the course of this inspection the registered manager left the home. The home is temporarily being managed part time by the manager of another home and the deputy manager of Kelstone Court. The senior staff need to improve the monitoring systems to ensure that the care provided is carried out to a good standard. Further work needs to be done to include and consult with residents and relatives about the running of the service on a regular basis. Clear information on any finances held on behalf of a resident must be in place. Regular health and safety checks are carried out in the home. Records do not provide clear information on the provision of health and safety training for all staff. EVIDENCE: Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 21 Senior staff have not provided adequate monitoring of the care and recording in the home. During the course of this inspection the home owners have made a commitment to improving the monitoring of the care provided. A significant number of requirements made at the time of the last inspection remain outstanding. Feedback from other professionals involved with home indicated that communication from staff in the home was not always good. Not all care and nursing staff are being provided with one to one supervision from a more senior member of staff. Action needs to be taken to make sure that all of these staff are provided with supervision at least six times a year. This will assist in ensuring that staff are working in line with the homes policies and procedures, allow staff the opportunity to discuss any concerns they may have and to monitor the training and development needs of individuals. Quality monitoring systems are in place. The organisation needs to carry out a review of the care provided on an annual basis with feedback from residents and their representatives taken into account when setting out the development plan for the following year. The finances for one resident were being managed by the responsible individual. A record of money received for this resident from the responsible individual was in place. It was noted that variable amounts were being deposited for the resident at various intervals throughout the year. The registered manager could not explain the reason for these variations or what this person was entitled to. Clear information on the allowances for this resident need to be in place. Health and safety checks are carried out. Records showed regular testing of the fire alarm system and the temperature of hot water. We observed one resident being assisted with an inappropriate type of hoist. This was raised with the registered manager. Records do not show that all staff have been provided with up to date training on moving and handling. The registered persons must ensure that all staff are provided with this training supplied by a suitably qualified person. The registered persons must also ensure that sufficient staff have been provided with up to date training on first aid so that a qualified first aider is available on each shift. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 X X 1 Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5A Requirement Confirmation that residents have been provided with the appropriate information on fees as set out in amended regulations from 1st September 2006 must be provided to the CSCI. The Registered Persons must make sure that they have confirmed in writing to the resident, that having seen or carried out the assessment the home can meet the needs of the person. The Registered Persons must ensure that a care plan is produced from the information provided by pre admission assessment and that a full care plan is produced without delay following admission to the home. Timescale of 24/02/06 not met) Timescale for action 14/05/07 2. OP3 14 (1) (d) 01/04/07 3. OP3 15 12(1) 20/03/07 Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 24 4. OP7 17 (1) (a) Schedule 3, 3 (j) (k) (m) (n) 25/03/07 The Registered Persons must ensure that all nursing care documentation meets the requirements f the Nursing and Midwifery code of professional conduct, performance and ethics. Documentation must provide clear evidence of the care planned, the decisions made, the care delivered and the information shared. Progress has been made in meeting this requirement. 5. OP7 17(1)(a) Schedule 3, 3(j) (k) (m) (n) 15/12/06 The Registered Persons must provide to the CSCI an action plan, with clear timescales for the review of: a) All wound care documentation b) All care plans. This requirement has been met. 6. OP7 15 (1) (2) The Registered Persons must ensure that all care plans include the full physical, social and emotional needs and wishes of residents along with how these will be met. Timescale of 01/02/07 not met. 25/03/07 7. OP7 15 (1) (2) The Registered Persons must ensure that care plans are compiled with the individual resident and or their representative. Timescale of 01/02/07 not met. 25/03/07 Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 25 8. OP8 17(1)(a) Sch 3 (k) 15/12/06 The Registered Persons must ensure that the record of wound care includes the type and frequency of treatment. A wound evaluation must be carried out at each dressing change and recorded. Timescale of 24/02/06 not met. This requirement was met during the course of this inspection. 9. OP8 OP7 17 (1) (a) Schedule 3, 3 (j) (k) (m) (n) 30/03/07 The Registered Persons must ensure that all documentation is accurate and up to date. Staff must not overwrite or erase care notes. All notes must be signed, timed and dated. Qualified staff must provide their full signature and their qualification to any notes they make. 01/05/07 The Registered Persons must ensure a record of the choices made by residents at meal times is maintained. A menu which meets the cultural and or religious needs of individual residents must be provided. Timescale of 24/02/06 not met. 10. OP15 16(2) 12(4) 17(2) Sch4 11. OP15 16(2) (i) 12(4) 01/05/07 The Registered Person must carry out a review meal times, to include: a) Consultation with residents on the menu. b) The use of bibs DS0000060496.V318319.R01.S.doc Version 5.2 Page 26 Kelstone Court Nursing Home c) How meals are presented d) The activities of staff during meal times. 12. OP16 22 The Registered Persons must 01/05/07 ensure that all staff are aware of their responsibilities in dealing with complaints or concerns promptly. All staff must be provided with clear guidance on complaints and effective communication. 01/06/07 The Registered Persons must ensure that all staff are provided with up to date training on the protection of vulnerable adults in a care home setting. 14. OP30 18(1)(c) The Registered Persons must ensure that a record of training completed and required is maintained for each member of staff including a record of any induction training. Timescale of 01/04/06 not met. 15. OP30 18(1)(c) The Registered Persons must carry out a review of the training needs of each member of staff. 16. OP27 12 The Registered Persons must carry out a review of the way work is organised in the home to make sure that residents needs are attended to promptly. 17. OP35 17(2) Schedule 4 (9) 01/05/07 The Registered Persons must ensure that clear records of money held on behalf of any DS0000060496.V318319.R01.S.doc Version 5.2 Page 27 13. OP18 13(6) 01/05/07 01/05/07 01/05/07 Kelstone Court Nursing Home resident are available. 18. OP36 18(2) The Registered Persons must ensure that all staff are provided with regular one to one supervision from a more senior member of staff. Timescale of 01/04/06 not met. 19. OP33 24 The Registered Persons must ensure that an annual review of the quality of care is carried out taking into account the opinions of residents and any other stakeholders. A copy of the report produced following any review must be provided to the CSCI Timescale of 01/04/06 not met. 20. OP38 13(1)(5) (6) The Registered Persons must ensure that all staff are provided with health and safety training form a suitably qualified person. All staff must be provided with training on moving and handling with regular up dates. Sufficient staff must be provided with up to date first aid training to ensure that a qualified first aider is on duty on each shift. 01/06/07 01/06/07 01/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 28 No. Refer to Standard Good Practice Recommendations Kelstone Court Nursing Home DS0000060496.V318319.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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. 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