CARE HOMES FOR OLDER PEOPLE
Kelvedon House 10 Clarkson Road Wednesbury West Midlands WS10 9AY Lead Inspector
Mrs Jean Edwards Unannounced Inspection 20th October 2005 08:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Kelvedon House Address 10 Clarkson Road Wednesbury West Midlands WS10 9AY 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) 0121 505 7775 Mr Sarwan Samrai Mrs Shindo Kaur Samrai Julie Hill Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. One service user (male) in the category of OP may also be MD(E). This will remain until such time that the current service users placement is terminated. Two service users (female) in the category OP may also be DE(E). This will remain until such time that the current service users placements are terminated. One service user identified in the variation report dated 29.12.04 may be accommodated at the home in the category MD(E). This will remain until such time that the service users placement is terminated. 23/05/05 Date of last inspection Brief Description of the Service: Kelvedon House is a private care home, providing residential care and accommodation for up to eighteen frail older people. The home is situated approximately a quarter of a mile from Wednesbury town centre, on main bus routes and close to the M6 motorway system. It is located close to easily accessible public transport routes to local areas and surrounding towns. There is limited car parking, two cars at the frontage, with some on road parking nearby. The accommodation is provided on two floors and consists of two double, and one en suite single and thirteen single bedrooms. There are two lounges and a dining area, eight toilets, three bathrooms and a shower. The Home has extensive gardens to rear of the premises, with some areas accessible to residents. There are no dedicated smoking facilities as such, though smokers at the home may use the staff room or small greenhouse in the garden. The home does not provide intermediate care. There is the staff team of 21 people including 16 carers and the registered manager. Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection visit has been conducted over one weekday. The purpose of the visit is to assess the home’s progress towards meeting the National Minimum Standards for older people and assess actions taken to improve areas highlighted at the announced inspection visit on 23 May 2005. Inspection methods used to obtain evidence and form judgements include: assessment of information supplied by the home, records of incidents, accidents, events, complaints and reports of visits by the owner. In addition records at the home have been examined and discussions have been held with the registered manager and members of staff on duty during the visit. Twenty standards haven been assessed or reassessed at this second inspection visit for the current year. A tour of the building has taken place, looking in particular at communal areas of the home, the bathrooms, toilets, kitchen and laundry areas, and a sample of residents’ bedrooms, with their permission. There are 16 people at the home, with one person in hospital. The majority of residents chatted to the inspector during the visit. Longer discussions have taken place with the residents whose care has been looked at in more depth. Discussions have taken place with relatives happy to give their views. Comments included we are always made welcome and the staff are welcoming, friendly and helpful. What the service does well:
The Proprietor and Registered Manager have responded to the previous inspection report with a comprehensive action plan, giving dates for the required improvements to be put into place. The registered manager is committed to making sure that improvements happen, where she has the authority to make decisions. Residents and their families are encouraged to be actively involved in planning the way that care is provided. Full details of each person’s likes and dislikes, preferred routines, hobbies and interests are recorded in a care plan. The care provided is regularly reviewed at meetings involving the resident and their family or representatives. Residents feel they can treat Kelvedon House as their own home and to be as independent as they wish. The staff team are caring, committed and flexible, often willing to work extra shifts. There is a warm and genuine rapport between staff and residents with lots of friendly conversation. Kelvedon House is generally clean, tidy, homely and comfortable. The tables in the dining room are attractively laid with freshly laundered tablecloths and
Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 6 small vases of flowers. Residents are able to have meals at times to suit them, for example some people came down to breakfast after 10:00 am. Other people have meals on trays in their own rooms. This inspection has been conducted with full co-operation of the registered manager, staff and residents. The atmosphere through out the inspection has been relaxed and friendly. What has improved since the last inspection?
The organisation has responded to a previous requirement and has confirmed to the CSCI full the details of the change of company name, address, and officers of the company. The plans showing how residents care is to be provided have been improved with more details about how decisions are reached and what choices can be made. There are improvements to written details about each persons care needs, which are regularly reviewed. These include how continence needs, skin condition and pain relief are managed. There are also fuller details in residents daily notes of care provided and what progress is achieved. There are considerable improvements to the way residents medication is ordered, stored, administered and recorded. There are also plans to provide staff with additional, accredited medication training. Residents and staff say that there are increased opportunities to take part in activities. One person particularly enjoys playing cards on a one-to-one basis with members of staff. The manager has successfully recruited and employed an experienced and skilled cook. She is in the process of revising the menus in consultation with residents. A number of different meal options are being offered on a trial basis to see which residents prefer. During discussions residents commented that meals have improved and one person regularly asks for seconds. New kitchen equipment has been provided, which includes pots and pans and a blender, improving the quality of food provided. Following the inspection visit in May 2005 and complaint investigation in July 2005, the manager has made sure that all staff have received up to date complaints awareness and training. This has been a topic of discussion during staff meetings. In response to a requirement made at the inspection visit in May 2005 additional storage for clothing and other personal possessions has been provided, as requested by the resident. He is a very pleased with his new furniture. Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 7 Since the last inspection six residents bedrooms have been redecorated in colour schemes according to each persons preference. One resident stated how pleased he is with his newly decorated room. In addition the majority of residents have had new bed linen, unless they have chosen to keep their own. There are new carpets on order for the corridors and ground floor communal rooms. The chosen colour scheme is plum and cream. The manager has completed with the process of updating information required for staff files, which are now very well organised and easy to audit. Good progress is being maintained to make sure that all staff are up-to-date with essential training such as health and safety, first aid and fire safety. The registered manager has introduced a system of regular formal supervision meetings with each member of staff. During discussions members of staff commented that the supervision and staff meetings are helpful and useful ways for people to share their views. The registered manager and staff have attended approved risk assessment awareness training. This has made them more aware of areas of risk associated with residents personal safety and areas of risk both within the homes environment and on any activities where the home has a duty of care. The manager and staff are now more able to put in place measures to minimise highlighted risks. What they could do better:
During examination of a residents case file it is noted that she has had a number of falls. Although there are records to show that each incident has been properly dealt with the home must also review and update this persons risk assessment in relation to the likelihood of further falls, and make sure that all measures possible are put in place to minimise known risks. The organisation must provide written evidence to the CSCI office, Halesowen that medication training for all staff responsible for administration of medication has been officially accredited. It is acknowledged that there are plans for further training, which has official accreditation. The home is experiencing difficulties obtaining sufficient supplies of Paracetamol for one resident, resulting in repeated prescription requests on a frequent basis. The registered person must write to the GP concerned to request adequate supplies of Paracetamol to be prescribed for this resident on a monthly basis, to resolve the needless frequent prescription requests. The activities programme displayed in the dining room advertises minibus trips. As the home is currently without a minibus, the registered manager must revise, update and display an accurate current activities programme. A previously outstanding requirement in 2002 to provide low surface temperature radiators or radiator guards and protection for exposed pipe work was deferred because of plans to rebuild the home. However there is no firm
Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 8 date for the provision of the new home, therefore the registered provider must now make progress to provide radiator guards or low surface temperature radiators and protect exposed pipe work accessible to residents. In addition, as an interim measure to safeguard residents, the registered manager must put in place written risk assessments, for all unguarded radiators and exposed pipe work and this must be done as a priority. It is acknowledged that the registered manager has improved the services provided by Kelvedon House. However for improvements to be continued, it is strongly recommended that the registered provider gives serious consideration to filling the vacant post of assistant manager or provides the registered manager with an administrative assistant. 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. Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 9 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 Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 The homes Statement of Purpose and Service User Guide are comprehensive, providing residents and prospective residents with details of the services the home provides enabling an informed decision about admission to be made. Standard 6 does not apply; this Home does not provide intermediate or respite care. EVIDENCE: There is a comprehensive statement of purpose and service user guide available, together with a copy of the most recent inspection report. The organisation has met the previous requirement to forward confirmation to the CSCI Satellite office full details of the change of company name, address, and details relating to company officers. The registered manager stated that a copy of the publication from the Office of Fair Trading: Guidance on Unfair Terms in Contracts in Care Homes has been obtained and progress being made to review the homes contract / terms and conditions. As part of the revision of the existing document there are plans to make sure that responsibility for paying fees and information relating to any breaches of terms and conditions are included.
Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 11 The home has had no new admissions since they announced inspection May 2005. All existing residents have copies of the existing contract on their case files. There is evidence that residents care and any developing needs are kept under regular review and are reassessed as needed, involving other agencies such as social workers or health care professionals where appropriate. Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,11 The health needs of residents are well met with good evidence of good multi disciplinary working taking place on a regular basis. The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure residents medication needs are met. EVIDENCE: From the sample of residents care plans assessed during this visit the manager has introduced the required improvements. The plans now contain full details of all care needs, which have been identified during the assessment and review processes. Discussions with individual residents people to communicate well verbally indicate that they are aware of their care plan and have agreed and signed the document. Residents are generally aware of their key workers name. There are comprehensive risk assessments in place for each resident. However it is noted that AF has had eight falls and although each incident has been appropriately dealt with the falls risk assessment must be reviewed and updated, with any additional control measures identified and implemented.
Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 13 Discussions with residents, relatives, staff and assessment of care records show that the home facilitates very good access to health services. There is good evidence of appointments and follow-ups with dentists, opticians, auditory and chiropody services. There is generally some difficulty for residents to be seen by NHS chiropodists, however the manager has made sure that all residents are registered with the Ring and Ride Service and are taken to attend NHS chiropody clinics. The home has a comprehensive medication policy and procedures. The policy is signed and dated in August 2004, as a matter of good practice it is recommended that this should be reviewed annually. However at the inspection visit in May 2005 a number of improvements were required. These included the need to ensure that adequate supplies of medication were ordered and available for each resident to be able to receive correct dosages, for example Paracetamol. Following a complaint in June 2005 relating to inadequate supplies of pain relief and subsequent investigation by the CSCI, an immediate requirement was issued to ensure that there are sufficient supplies of medication for residents at all times. From assessment of medication records, observations of medication administration and discussions with residents and staff the systems for providing residents medication needs are now generally satisfactory. The home is experiencing difficulties in obtaining sufficient monthly supplies of Paracetamol for one resident (JM), who requires consistent pain relief, two (500 mg) tablets four times each day. The GP will currently only prescribe 64 tablets at a time, which means that the home has to request additional repeat prescriptions each month. The organisation has not yet provided the CSCI with evidence that medication training for all staff responsible for administration of medication has been officially accredited. This requirement remains outstanding. The manager has indicated there is a plan for further training through an accredited training course. Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15 This home has systems, which ensure that residents are able to exercise their rights as citizens. The home has made good progress to improve the provision of a varied menu to enable residents to exercise choice and control over their diet and what they eat. EVIDENCE: During discussions with residents and staff the commented that there is an improved level of social activities taking place, although it is recognised that some people may not wish to be involved in structured activities. There are now more spontaneous activities taking place, for example staff playing cards with residents on an individual basis. One resident commented how much he enjoyed a game of cards; and a member of staff was observed to be engaged in a card game with another resident in the quiet lounge during this visit. The staff have now resumed the practice of recording participation in activities on an individual basis, noting successes and refusals. There is a notice in the home advertising forthcoming bonfire night celebrations. The activities programme displayed in the dining room was not up to date and advertised minibus trips twice a week. The homes minibus is no longer in service. The activities programme displayed must accurately reflect activities available.
Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 15 The manager has met the immediate requirement issued as a result of a complaint to facilitate regular attendance at Mass at the Roman Catholic Church of choice for the resident EB. The manager now makes block bookings with the Ring and Ride Service. Assessment of residents case files and discussions have provided evidence that the manager proactively facilitates each persons right to vote if they wish. There is evidence that residents are enrolled on the electoral register and have a proxy or postal vote to allow them to vote in elections. An experienced and skilled cook has commenced employment at the home and is experimenting with new meal options on a trial basis to find out which meals residents would prefer to be included on the revised menus. There is a general consensus from residents and staff that food provided has improved. A member of care staff rotad to undertake catering duties, cooked the meals on the day of this visit, as the cook was off duty. The mid day meal options on the day of this visit include: chicken curry or gammon and vegetables. Both meals were attractively served and enjoyed by all residents. Only one resident commented that the portions she had been given are too large. As previously required residents must receive food portions sizes according to their preference. Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 The home has an improved complaints system with evidence that residents feel that their views are listened to and acted upon. Arrangements for protecting residents are generally satisfactory, safeguarding them from possible risk of harm or abuse. EVIDENCE: The home has a satisfactory complaints procedure, which is displayed in the home and contained in the service user guide. The home has received one complaint since the inspection in May 2005. The complainant, a relative, initially raised issues relating to insufficient supplies of pain relief medication, inappropriate use of her mothers room, lack of disposable gloves and issues relating to not meeting two other residents needs. The complainant also made a formal complaint directly to the CSCI. The subsequent investigation upheld all elements of the complaint and immediate requirements were issued to the home. A satisfactory written response has been received from the home providing evidence that the immediate requirements for improvement have been met. A follow-up assessment of the areas of concern at this visit has been satisfactory. The manager has made sure that all staff have received up to date complaints awareness and training, this is mainly been provided as part of staff meetings and individual supervision sessions. The previous requirement to provide appropriate staff awareness and training regarding protection of vulnerable adults is partly met.
Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,24,25,26 There is currently some uncertainty about the plans and timescale for completion of the proposed new building. The manager has a good understanding of the areas where the home needs to improve and some proactive planning is now in place indicating how this improvement is going to be resourced and managed. The standard of the décor within this home is generally acceptable with evidence of some improvement through general maintenance and redecoration. EVIDENCE: There are no firm plans or timescale for the commencement or completion of the proposed new home on the site of Kelvedon House. The manager is therefore making progress to improve the existing facilities for residents currently living at the home. A redecoration programme of residents bedrooms has started and six bedrooms have been attractively redecorated. Additional storage for clothing and other personal possessions has been provided for the resident (BD), as required at the inspection visit in May 2005.
Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 18 The previous requirement to provide radiator guards / low surface temperature radiators and exposed pipe work accessible to residents was deferred due to plans for a new home. However as there is no definite timescale for the building progress must be made to safeguard existing residents and as an interim measure written risk assessments, with control measures must be implemented as a priority. The requirement to provide separate hand washing facilities, for staff, in laundry area, remains outstanding. Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 Staff morale has improved resulting in reduced staff turn over and good attendance that in turn results in residents receiving a good and consistent service. EVIDENCE: The home has a team of 21 people including the registered manager and 17 carers. One person is about to leave the home’s, for a change of career. Assessment of staffing information including staff rotas shows that the home is currently providing adequate levels of care staff. The staff files for new and existing staff are well organised and contain all documented information required, ensuring that recruitment and retention processes are robust. The registered manager has increased the number of formal supervision sessions and devised an annual schedule of supervision meetings to ensure that all care staff receive a minimum of six documented supervision sessions each year. The registered manager has made very good progress to improve the care and systems at Kelvedon House. However it is recommended that the registered provider gives serious consideration to filling the vacant post of assistant manager or provides the registered manager with an administrative assistant, to ensure that improvements are consistently maintained. The residents and relatives spoke to are complimentary about the friendliness, helpfulness and kindness of members of staff.
Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35,36,38 The registered manager continues to be supported by her senior staff in providing clear leadership throughout the home with staff demonstrating a good awareness of their roles and responsibilities. The home has effective policies and systems to safeguard residents financial affaires. EVIDENCE: Discussions with residents and members of staff indicate that there is improved communication in the home. People feel that they can share their views, opinions and raise concerns and that they will be listened to and ideas and issues will be acted upon. The last residents meeting was in May 2005. Some residents feel that although not all residents are willing to attend meetings, meetings are valuable and would like them to be held more frequently. It is strongly recommended
Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 21 that an annual schedule of residence meetings is devised and displayed, together with notes of previous meetings, to encourage participation. The home had undergone a fire safety inspection of the day prior to this visit, 19/10/05. The manager stated that the fire safety officer was satisfied with arrangements at Kelvedon House and there are no outstanding recommendations from his visit. A sample of maintenance service records have been examined, these are generally satisfactory. However the manager must forward documentary evidence of up to date refresher fire training sessions and fire drills for all staff, to the CSCI office, Halesowen. The home is not currently undertaking regular documented checks of wheelchairs and the home does not have an asbestos check / risk assessment. There is no documentary evidence available at this visit of the regular accident analysis and an audit of accident records since the last inspection has not been possible. A documented accident analysis must be forwarded to the CSCI office, Halesowen. Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 X 3 X X 3 2 2 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 X X 3 3 X 2 Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 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 5(1)(c) Timescale for action 1) To review the contract / terms 01/12/05 and conditions using the publication from the Office of Fair Trading: Guidance on Unfair Terms in Contracts in Care Homes (Timescale of 31/12/04 and 31/07/05 is not fully met) 2) To expand existing contracts/terms and conditions to include: responsibility for paying fees and breaches (Timescale of 31/07/05 is not fully met) To review and update the falls risk assessment for AF (following 8 falls) 1) To provide documentary evidence that medication training for all staff responsible for administration of medication has been officially accredited. Planned to be action through an accredited training course. (Timescale of 1/12/04 and 30/06/05 not fully met) Requirement 2 3 OP7 OP9 13(4) 13 (2) 01/11/05 01/12/05 4 OP12 16(2)(m) To revise, update and display the 01/12/05
DS0000004847.V260624.R01.S.doc Version 5.0 Page 24 Kelvedon House 5 OP15 (n) 16(2)(g) (i) current activities programme 1) To ensure that service users receive food portions sizes according to their preferences (Timescale of 30/11/04 and 30/06/05 is not fully met) To provide appropriate staff awareness and training regarding protection of vulnerable adults (Timescale of 31/12/04 and 31/07/05 is not fully met) 1) To progress the provision of radiator guards / low surface temperature radiators and exposed pipe work accessible to residents 01/11/05 6 OP18 13(5) 18(1)(c) 01/12/05 7 OP25 13(4) 23(2)(p) 01/12/05 8 OP26 16(2) 23(2) 9 OP30 13(4) 18(1)(c) 23(5) 2) To devise and implement written risk assessments, as an interim measure, for all unguarded radiators and exposed pipe work, as a priority To provide separate hand 01/12/05 washing facilities for staff in laundry area. (Timescale of 1/12/04 and 31/07/05 is not met) 1) To ensure ALL staff employed 01/11/05 have up to date mandatory training as follows; fire training & drills x 2 each year, (by 31.7.03); moving & handling, infection control, with documentary evidence of completion (Timescale of 31/12/04 and 31/07/05 is partly met) 2) To forward documentary evidence of refresher fire training provided for ALL staff to CSCI office, Halesowen (Timescale of 31/07/05 is not fully met) Additional training due 25/10/05 Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 25 10 OP38 13(4) 1) To resume the regular documented accident analysis, forwarding results to the CSCI office, Halesowen 2) To undertake regular documented wheelchair checks in addition to an annual service 3) To ensure that an asbestos risk assessment is undertaken by a competent person 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP9 OP9 OP27 Good Practice Recommendations That the registered person makes a written request the GP for JM to be prescribed adequate supplies of Paracetamol to last each month That the medication policy and procedures dated August 2004 is reviewed and updated as necessary That the registered provider gives serious consideration to filling the vacant post of assistant manager or provides the registered manager with an administrative assistant. Kelvedon House DS0000004847.V260624.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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