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Inspection on 05/12/07 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 5th December 2007.

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 people who use the service and staff. People who use the service told us, "I am very happy here", "it`s very nice here", "everyone is very helpful" and "nothing is too much trouble for the staff". A visitor to the home told us they "couldn`t fault the place". The service provides a good range of activities within the home and frequent opportunities for people to take part in trips out. People who use the service told us "I like the trips out" and "I like going to the pub". There are good links with churches and schools in the local area. Staff felt that they were well supported and that they worked well as a team. Everyone we spoke to and who sent back a questionnaire knew how to make a complaint and all said that the home was always clean and tidy, one person described their room as "spotless".

What has improved since the last inspection?

Some improvements have been made to the care planning and assessments. To make sure that everyone is provided with a balanced, varied diet an individual record of food is now kept. Staff have made some progress in including the cultural needs and wishes of people with regard to their diet. Improvements have been made to the environment. The extension has been completed, the kitchen has been re furbished and locks, which can be opened from the outside in an emergency, have been fitted to bathroom doors.

What the care home could do better:

Further work needs to be done on care planning to ensure that where assessments indicate a need these are reflected in the plans and the plans provide staff with information on how the care is to be provided. More detail needs to be included if staff are to provide person centred care.A review of mealtimes needs to be carried out to make these times more of a pleasant social event. Staff should review the way in which care is provided particularly around bathing and showering to make sure that the wishes of individuals are met. Staff training records need to be up to date to show that all staff are receiving appropriate training. To assist in ensuring the safety of people who use the service all staff must be provided with training on Safeguarding Adults. In future any new staff should be providing a full employment history and signing a statement on their physical and mental fitness. A review of the way in which records of money held for individuals living in the home should be carried out to make sure that these records can be checked on a regular basis. The organisation should make sure that the acting manager is not included in the qualified staff numbers on duty. This will allow for the manager to supervise and monitor the care and documentation.

CARE HOMES FOR OLDER PEOPLE Kelstone Court Nursing Home Cambourne Road Morden Surrey SM4 4JN Lead Inspector Liz O`Reilly Unannounced Inspection 10:00 5 & 10 December 2007 th th 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.V356656.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.V356656.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.V356656.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th June 2007 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. Fees for this service are from £575 to £625 per week. Kelstone Court Nursing Home DS0000060496.V356656.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 over two days. The inspectors had the opportunity to speak with people who use the service, staff, visitors and the acting manager. Surveys were provided for people who use the service and staff. The organisation have completed their own assessment of the service as required by the CSCI. All of these sources as well as observations made at the time of these visits have been used to reach the judgements in this report. What the service does well: What has improved since the last inspection? What they could do better: Further work needs to be done on care planning to ensure that where assessments indicate a need these are reflected in the plans and the plans provide staff with information on how the care is to be provided. More detail needs to be included if staff are to provide person centred care. Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 6 A review of mealtimes needs to be carried out to make these times more of a pleasant social event. Staff should review the way in which care is provided particularly around bathing and showering to make sure that the wishes of individuals are met. Staff training records need to be up to date to show that all staff are receiving appropriate training. To assist in ensuring the safety of people who use the service all staff must be provided with training on Safeguarding Adults. In future any new staff should be providing a full employment history and signing a statement on their physical and mental fitness. A review of the way in which records of money held for individuals living in the home should be carried out to make sure that these records can be checked on a regular basis. The organisation should make sure that the acting manager is not included in the qualified staff numbers on duty. This will allow for the manager to supervise and monitor the care and documentation. 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.V356656.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.V356656.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): 1, 3 & 6 People who use this service receive good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with information on what they can expect from the service in the Service User Guide. No one is admitted to the home until a full assessment has been undertaken. For people who are self funding and therefore do not have a Care Management assessment, the assessment is carried out by a senior member of staff from the service. This home does not offer intermediate care. EVIDENCE: Each person is provided with a copy of the Service User Guide which sets out what they can expect from the home. People told us they felt they were given enough information about the service before they moved in. We found copies of the guide in bedrooms. The organisation is aware that the Service User Guide will need updating to take into account the change in manager. When updating the guide Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 9 consideration should be given to providing the information in a more easily accessible format. We found pre admission assessments in place. This provides staff with information on the needs of individuals before they move in and is used to set up an initial care plan. Kelstone Court Nursing Home DS0000060496.V356656.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 People who use this service receive adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Care plans could give more detail on how the needs and wishes of people will be met and be more person centred. Care plans need to reflect the assessment of needs and wishes. Medication is well managed. The way in which people are supported to bathe or shower should be reviewed. EVIDENCE: We looked at a sample of care plans. The amount of information contained in the care plans was variable. We found little information on the cultural needs of individuals and information on the personal care needs tended to be general for example under personal hygiene staff had stated “full care”. Certain staff had added more personal information on the preferences of individuals particularly around food and times for getting up and going to bed. In order to provide a more person centred plan staff need to include much more detail on the wishes of people and the way in which these are going to be met. Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 11 Assessments of risk had been carried out for individuals but these were not reflected in the care planning. For example an assessment of the risk of pressure sores had been carried out for each person but where these showed high risk no information was available as to what action had been taken to lower the risk. In one instance an assessment indicated the person was experiencing pain but there was no information in the care plan about how this was to be reduced or how frequently staff should monitor the person. We saw one person given a hot drink in a plastic two handled cup and staff did not hear when this person said ‘it’s too sweet, it’s got sugar in’. One of the inspectors returned the cup to the tea trolley and a new cup of tea in a teacup was provided by the manager who stated that this person does not take sugar. The care plan did not state this person used a plastic cup or that they did not like sugar in their tea. We were informed by a visitor that this person used to go to bed for a short while after lunch but that this no longer happened. This information was not in the care plan. Information on the social needs of individuals was brief and in one instance contained no information. We are aware that the activities coordinator is in the process of completing assessments for each person. This information should be included in the main care plan to evidence a ‘whole person’ approach to care. Reviews of the care plans were seen to be carried out. Each person is allocated a key worker from among the care staff. Key workers provide a review for each person who uses the service which is kept in their bedroom. People who use the service and their relatives are invited to respond to the review or report any concerns on the documents should they wish. This provides evidence of the service consulting and listening to people who use the service. We found some of these documents contained good information on the history of the individual and their preferences, others contained little more than a list of requests from families. Staff should make sure that these reviews are kept up to date. In a number of instances we saw that a review had not taken place for some time. We found a bath list in place which set out the days allocated for each person to have a weekly bath or shower. Although the acting manager stated that this was only used to indicate the minimum for individuals we found no evidence that people were offered a bath or shower more frequently. Feedback from one person in the home’s own surveys included the wish to have a shower more than once a week. Staff should review the way in which they provide care to make sure that it is provided in an individual manner which respects the needs and wishes of the person. People who use the service were seen to be well dressed and clean. However a number of ladies had lank hair which appeared not to have been washed or set recently. Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 12 The health care needs of people who use the service are mainly met. Records showed staff support people to access health care services. People who use the service told us that they felt their medical needs were always met. The care plans need to include the actions taken to maintain the health of people who use the service. Medication was found to be well managed with good records kept. Kelstone Court Nursing Home DS0000060496.V356656.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 People who use this service receive good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The home offers a good range of activities and outings. Improvements could be made to make sure that mealtimes are a more positive social occasion. EVIDENCE: The home employs an activities coordinator and there are a good variety of group and one to one activities on offer. People who use the service told us that they enjoyed quizzes, reading aloud, card games, art and crafts and recently making Christmas cards. One person told us they “really like the poetry”. People told us they particularly enjoyed outings to local pubs and parks. Recent outings had included a trip to Brooklands, Christmas shopping and a pub lunch. It is planned that an outing is available at least once a month. Staff have also helped to organise in house events including a Halloween party and a fund raising coffee morning for MacMillan care. Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 14 Running up to the Christmas period groups from the local churches and the boys and girls brigade were planning to visit to sing carols. A Christmas party in the home and Christmas lunch at the local pub were also planned. The activities coordinator was working on a history sheet for each person which includes information on their family and life experiences. This information will assist staff in providing more person centred care and provide staff with an insight into the individual experiences of the people they support. Consideration should be given to key workers and named nurses being more involved in this work. The feedback from people who use the service about the food was mixed. The majority of people said they “sometimes” liked the meals. One person told us their favourite meal was breakfast. We are aware that the menu is regularly discussed at residents meetings and this should continue. A menu showing a good variety of food and alternatives available at each mealtime is in place. To ensure that each person is receiving a well balanced diet an individual record of food is kept. Staff make sure that people are offered choices by asking during the course of the morning what they would like for lunch. People are offered snacks and sandwiches after the last meal of the day and this should be added to the published menu to show that people who use the service do not have a long gap between the last meal and breakfast. We were informed by staff that people are provided with culturally appropriate meals through family bringing in food, keeping meals in the freezer, discussing preferences with families and regularly cooking rice and fish. We saw one person being provided with rice and curried fish on the day we visited. In order to show that the needs of people from different cultures are being fully met care plans should include the outcomes of discussions on preferences and a menu which meet the cultural and or religious needs of individuals should be produced. Staff add calories to food for those people who are at risk of or are underweight. At the time of the last inspection we suggested that changes could be made to improve mealtimes for people who use the service. We saw that the new extension was partially being used at mealtimes but tables were not set, there were no condiments on the table, staff were told by the manager to sit down when helping people to eat and part of the dining area was taken up with chairs and a television and quite cluttered. The majority of people were eating their meals in their chairs in the lounge area. Improvements could still be made to make mealtimes a more social occasion. Kelstone Court Nursing Home DS0000060496.V356656.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 People who use this service receive good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. People who use the service know who to speak to if they have any concerns or complaints. Training in Safeguarding Adults supports staff in protecting people. However not all of the staff have received this training and this needs to be addressed. EVIDENCE: A complaints procedure is in place and made available to each person living in the home. Systems are in place for all complaints to be recorded along with actions taken and outcomes. All of the people who use the service we spoke to and who completed a questionnaire knew how to make a complaint. The service has an internal procedure for dealing with any concern or allegation of abuse. A copy of the local authority procedure is also available to staff. The record of staff training shows that not all staff have received training on safeguarding adults. To ensure the safety of people using the service all staff need to have training in this area to make sure that they can recognise abuse and know what action to take should anyone report possible abuse to them. Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 16 Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 17 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, 24, 25 & 26 People who use this service receive adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The home owners continue to make improvements to the environment. The home is clean and tidy. People who use the service are provided with comfortable bedrooms. The large lounge area is restrictive and at times congested but the addition of a new extension offers an area where people can sit quietly or meet with friends in more privacy. The needs of people who use the service and smoke are not met. EVIDENCE: Since purchasing the home the owners have made and continue to make significant improvements to the environment. Since the last inspection the kitchen has been refurbished to a good standard and the extension has been completed. Locks which can be opened from the outside in an emergency have been fitted to bathrooms which improves the privacy of people who use the service. Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 18 People who use the service told us they were happy with their bedrooms. We saw that individuals have personalised their rooms with their own possessions. People told us that their room was “spotless” and “I love my bedroom”. There is a large open plan lounge area which can become congested and offers little space for people to meet with visitors in privacy. In the home’s own survey one person raised the issue of there being little space between chairs. There are a significant number of televisions in this area and we observed that it can be difficult for people to watch or hear particular programmes. This is a problem that the present owners have inherited and the addition of an extension on the side of this room provides a small dining room and space for people to meet with visitors should they wish. The service states that this is a no smoking environment. At least three people who use the service smoke. When they wish to smoke they must go or be taken to the garden. On the first day of inspection we observed one person sitting with wet hair and trousers after being taken out in the rain for a cigarette. The acting manager informed us that plans were in place to erect a shelter in the garden for people who smoke. Urgent action must be taken to ensure that people who live in the home and smoke are provided with appropriate, warm and dry accommodation. Everyone we spoke to and who completed a questionnaire said that the home as always fresh and clean. Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 19 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 this service receive good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. There are enough staff on duty to meet the needs of individuals. People who use the service are protected by the recruitment checks carried out. Staff are offered good opportunities for training but the training record needs to be kept up to date. EVIDENCE: At least two qualified nurses are available during the day with five carers in the morning and four carers in the afternoon and evening. At night one nurse and three carers are on duty. Staff told us that there were always enough staff to meet the needs of the people living in the home. Comments from people who use the service were positive about the staff group. One visitor told us, “staff always happy and respond to requests” We saw good interactions between staff and people living in the home. Staff were polite and caring in their manner. Staff told us they were given good opportunities to take part in training which assists in keeping up to date with good practice. The record of training needs to be kept up to date. Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 20 We looked at a sample of staff records. These were well maintained. Before anyone is employed checks are carried out including Criminal Records Bureau checks and references which assists in protecting people who use the service. In future staff will need to provide a full employment history with explanations for any gaps and sign a declaration that they are physically and mentally fit to carry out their role. Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 21 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 this service receive good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The manager’s post is vacant and has been for some time. A manager, who is supernumerary to the staff numbers should be appointed as soon as possible. People who use and are connected with the service are consulted on the home through surveys. The records of individual finances could be better organised. Staff make regular checks on the environment and equipment to protect the health and safety of people who use the service. EVIDENCE: The home has been without a permanent manager for some time. The owners have appointed an appropriately qualified and experienced acting manager in the interim. However this person is the deputy manager and is therefore taking on this role without the support of a deputy manager and while still Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 22 being included in the qualified staff on duty. This, we feel has an impact on the amount of time the acting manager can spend on managing the service. We are aware that the home owners were hoping to appoint a manager within weeks of this inspection. Feedback from staff on the support provided by the acting manager was positive. Staff felt they were well supported and that they manager was available to them should they have any problems. One visitor told us “the manager is very good”. People who use the service and their families are consulted on how the home is operating through meetings and surveys. Surveys are also sent to other professionals involved with the service. This information is collated. The quality monitoring and assurance system should be expanded to carry out a review of the care provided which takes these results into consideration and the production of an annual development plan. Facilities are available for people who use the service to deposit small amounts of money in the home for safekeeping. We could not fully review the records kept as receipts for, in some cases many years, were all kept together. We did note that, if anything, people appeared to have more money in their account than the records would suggest. The way in which these records are kept should be reviewed and it is suggested that receipts from previous years be kept separately. We found good records kept of checks on the building and equipment which ensures the health and safety of people who use the service, staff and visitors. Staff were found to be vigilant in checking on equipment with new slings being ordered for hoists to replace those which had become worn. Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 3 17 X 18 2 3 X X X X 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement In order to make sure that people are provided with the care they need and in the way they wish care plans must include:• Details of how needs and wishes will be met. • Details of the social, cultural and religious needs and wishes of individuals and how these will be met. In order to ensure that the health, safety and welfare of individuals is protected staff must include a plan of care for any assessed risk which sets out how these risks will be minimised. A review of mealtimes and menus must be carried out to ensure that:• The needs and wishes of individuals are met in relation to culture and or religion. • Mealtimes are a relaxed social event. • People who use the service are provided with DS0000060496.V356656.R01.S.doc Timescale for action 01/04/08 2. OP7 14 01/04/08 3. OP15 12 (1)(4) 01/04/08 Kelstone Court Nursing Home Version 5.2 Page 25 4 OP30 18(1) tables laid with at least basic condiments. To ensure that people who use the service are supported by appropriately trained staff an up to date training record must be maintained. All staff must be provided with training on Safeguarding Adults. To ensure the health and safety of people who use the service action must be taken to provide suitable warm and dry accommodation for those people who smoke. 01/04/08 5. OP25 23(2)(a) 01/04/08 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. Refer to Standard OP1 OP10 Good Practice Recommendations Consideration should be given to providing the service user guide in a more easily accessible format. Staff should be reviewing the way in which they proved care particularly around bathing and showering to ensure the care is provided in a manner which respects the needs and wishes of the individual. The snack provided after the main meal of the evening should be included on the published menu. The hours of the acting manager should not be included in the qualified staff hours on the shift. A review of the care provided and development plan should be produced taking into account the views of people who use the service. The way in which the records of money held on behalf of people who use the service is kept should be reviewed. 3. 4. 5. 6. OP15 OP31 OP33 OP35 Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Kelstone Court Nursing Home DS0000060496.V356656.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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