Inspection on 14/05/07 for Keneydon House

This inspection was carried out on 14th May 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Keneydon House 07/04/09

Keneydon House 08/04/08

Keneydon House 23/05/06

Keneydon House 10/01/06

Keneydon House 23/06/05

Keneydon House 21/01/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Keneydon House 2 Delph Street Whittlesey Cambridgeshire PE7 1QQ Lead Inspector Don Traylen Key Unannounced Inspection 14th May 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Keneydon House DS0000061370.V338315.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. Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Keneydon House Address 2 Delph Street Whittlesey Cambridgeshire PE7 1QQ 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) 01733 203444 01733 202648 adrcare1@btconnect.com ADR Care Homes Ltd Eileen Redhead Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (21) of places Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Old Age not falling into any other category (OP) - 21 (both sexes) Dementia - over 65 years of age (DE(E) - 21 (both sexes) Date of last inspection 23rd May 2006 Brief Description of the Service: Keneydon House is a care home registered to provide for 21 people over the age of 65 years. The home is situated in the town of Whittlesey, near Peterborough and is close to local amenities. The home is an older property built approximately in 1890. The accommodation is on two floors accessible by stairs or a chair lift to the first floor. A ground floor extension housing six bedrooms was addedd approximately 15 years ago. There are 13 single and 4 double rooms and a large garden to the rear of the building. The home provides day care provision on Mondays, Wednesdays and Fridays for between 1-3 people as well as preparing and delivering meals for up to 14 people who live in the immediate vicinity. The people who use the day service share the same facilities enjoyed by the permanent service users living at the home. The manager stated that the fees asked by the home at the time of this inspection ranged between £343 per week and £430 per week depending on whether funded by a Local Authority/PCT or privately purchased and according to assessed needs. The local PCT pay between £343-£419 per week according to needs. Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors, Don Traylen and Alison Hilton, carried out this inspection on the 14th May 2007. The responsible individual who is a director of ADR Care Homes Ltd, was at the home for a brief period when the inspectors arrived. The registered manager was available throughout the inspection and discussed in detail with the inspectors the issues that were found and that were fed back to her during the inspection. A senior carer who deputises for the manager was present for part of these discussions. A number of people who live at the home were spoken to and observations of their care were made and a tour of the building was carried out. A visiting relative and a visiting District Nurse were spoken to. Two people who recently moved into the home and who are both funded by the local authority/PCT, were case tracked to assess the preparation, the planning and the arrangements made for their care. Comments from the two local Primary Care Trusts were invited about their experiences of funding placements for people living at the home. What the service does well: The service provides friendly and kind staff to deliver care. Staff are polite and appear to be considerate at all times. The manager is always friendly and eager to help and sets an example by her attitude. Relatives comments were positive and reported that the care is benefiting people living in the home. Staff wear uniforms. All care assistants bar two have achieved NVQ level 2 awards. The care plans for two service users recently admitted had been written by the home. The home had to re-assess and create a care plan when one service user’s needs had not been sufficiently described in the CPA assessment the home had received from the mental health team. The home has written good descriptions of both person’s habits and routines that created an informative and useful picture of the person, so that care assistants were able to provide appropriate care. Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: • Risk assessments were absent from care plans in the case of two people who had recently moved into the home. Some of the risks were known to the home but there were no written, or recorded plans to identify and manage risks. Risks of highest priority concerning the two recently admitted people were falling, mental health management and associated medication needs. However, some of these risks were known by the manager who described the strategy for reducing these risks and what the staff were doing to reduce some of these risks. Because of the nature of some risks, referrals to community health services should be considered, to ensure people have access to a full health service, as soon as they move into the home. Medication records must be accurately maintained and include the amount of medication received by the home when a person moves into the home. The manager and staff were familiar with the overall plans and intentions of the provider to improve the home. The home did not have any written plan or schedule available to show the inspectors of these improvements as referred to in Standard 19 of the National Minimum Standards for Care Homes for Older People. There were no written or recorded risk DS0000061370.V338315.R01.S.doc Version 5.2 Page 7 • • Keneydon House assessments to manage the risks presented by the extensive refurbishment and redecoration of the home. However, the manager and staff were acting to their plan to manage and prevent risks and this was clearly demonstrated and described by two care staff and the manager. It was discussed with the manager that there must be a written risk assessment to address these hazards, so that people living in the home and staff, are not exposed to unnecessary risks. • The smell of stale urine was noticed in different parts of the home. This fact has been reported in previous inspection reports. The odours were noticed by both inspectors and were made known to the manager during the inspection. It is expected that these odours will be eradicated when the refurbishment is completed. More attention must be given to the risk of infection and infection control. Staffing levels must be reviewed so that people’s needs are assured by suitable numbers of persons working at the home. Staff recruitment must be a more rigorous process to ensure people who live at the home are protected. • • • 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. Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6, Quality in this outcome area is good. People’s needs are assessed prior to moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two peole who had recently moved into the home were case tracked and their assessments read. A Care Programme Approach (CPA) Assessment information given to the home was brief and limited and did not give the home adequate information to prepare them for all of that person’s needs. This was the case discovered during a respite admission arrangement had been made for one person and whose care arrangement subsequently became permanent in the home. The manager expected to receive sufficient information prior to the original respite admission. The home had gathered additional and significant new detail of that person’s needs through their own assessment and Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 10 observations. This situation did leave the home in a position of needing to establish all of the persons needs. This included a review of the prescribed medication that had not been addressed in the CPA assessment, but had been noted by the home who were in the process of arranging. During the inspection one of the inspectors spoke to the Care Manager who was dealing with this case and requested that the assessment for behavioural needs that had been conducted, was given to the home. A comprehensive care management assessment, for the other person who had been recently admitted to the home, was provided prior to the planned admission. The home does not provide intermediate care and therefore standard six was not assessed. Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10, Quality in this outcome area is adequate. The care needs for people who use this service are fully acknowledged and known by the home, but are not always completely recorded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Despite a detailed risks assessment not having been recorded and missing from care plans, the plans were clear and uncomplicated documents that gave a precise picture of the care that was necessary. It was judged that these care plans are an indicator of some further improvement since the last inspection because of the efforts that had been made when the pre-admission assessment information was minimal. Two care plans were assessed for the two people who were care tracked during the inspection. The plans related to the person, whilst the documents had been neatly recorded and presented in a format that was easy to read. In one instance, the plan had been constructed after the PCT Care Manager had given only minimal assessment detail to the Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 12 home. The plan recorded details of each person’s needs beginning with an introduction, frequent use of the person’s name and written in a style that clearly focused on the person. There was a ‘care at a glance’, an informative snapshot of care and the routines that did not include night time, but only the day time. The plan included routines of detailed care, for washing and personal hygiene, likes and dislikes, general health and social activities that was a comprehensive list of care. A dependency score had been included in these plans. Risk assessments had not been written for the two people case tracked. This was discussed at length with the manager and with the senior carer during the inspection. The home did have a blank document for a ‘bed rail risk assessment’. The manager was aware of some of the risks and had actions in place to reduce them, such as ways to prevent some potential falls and the reasons for the falls that had been experienced by each service user. However, the different risks were not listed. The action to prevent some of the known risks that had been identified in the assessment and the care plan should include actions to request community health service to give specific advise about needs. These risks may have needed the intervention of community health services to support these two people living at the home. It was discussed with the manager that requests for community health services to support people are made as soon as they move into the home whenever this is recognised. One of the two people being tracked had not had been referred to the GP to review their prescribed medication, although the GP had visited to attend to that person. Another person, who had fallen and been monitored by the care staff, had not been referred to her GP for the bruising and effects of this fall. The Medication Administration Records (MAR) were checked and found to be accurately recorded,apart from the records of one person whose record had been hand written on a MAR sheet when that person came to the home with their own medication. The numbers and amounts of medication brought into the home had not been recorded, and it was not possible to check the amounts of medication that should have been present at the time of inspection. The manager had contacted the GP who was in the process of prescribing the medication for the first time for this newly registered patient and the home’s records will be corrected when new administration sheets are used with the new prescription. Some entries were made in the daily progress sheets of ‘refused tablet’ and there were subsequent recordings of the medication being taken, when the person was offered the medication later. The specific medication that was refused was not recorded and the MAR sheet reflected some of these refusals but had not included all of them. In the medication storage trolley there wre three different types of prescribed medication for three different people that were in packets and had not been supplied in the blister packs. Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 13 Each service user that was spoken to, plus a visiting relative and a District Nurse, all stated that people were treated kindly and with respect by the care staff. The visiting spouse of one person stated that the care is “brilliant” and that her husband gets on well with the carers and that she had been consulted in the care plan made by the home. Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, Quality in this outcome area is good. People who live in the home enjoy a quite and peaceful lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People were provided with staff initiated activities that included bingo and dominoes, on a regular routine. A singer occasionally performs at the home and other musical and exercise activities take place. Generally, people were observed sitting together in the lounge and some remained in the dining room playing dominoes and were managing this as an independent group. A meal was observed being eaten at lunchtime and people remarked that they had enjoyed the food and always had enough to eat and drink. Keneydon House DS0000061370.V338315.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 adequate. Vulnerable people are protected by the home in practice, but it has not been clearly stated in their policy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure was posted on a notice board near the main entrance. A complaints book was available and contained two complaints, one of which was dated 2004 and one dated mid 2006. Three service users and a visitor stated they would make a complaint if they felt they wanted to. Staff are trained in protecting vulnerable adults from abuse and some had attended this training on the day of the inspection. Two staff stated they would report any abuse to the manager or to “Social Services” and knew where the contact details were in the office. It is recommended that the contact telephone numbers for reporting an allegation of abuse be posted somewhere near to the entrance, so that service users’ protection is further promoted by the home to facilitate easy access to these contacts as has been suggested by Cambridgeshire County Council adult protection trainer for “Key Practitioner” awards. The home’s policy, called, “Policy on Application of the Vulnerable Adults Register” is not a statement or policy about the homes position towards Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 16 safeguarding the vulnerable people living at the home. Although the document had been reviewed in November 2006, it should include the home’s attitude towards and actions it will take, should abuse be revealed, or alleged in the home. The home has previously demonstrated they comply with the Cambridgeshire County Council guidelines. Keneydon House DS0000061370.V338315.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): 19,25,26, Quality in this outcome area is adequate. People who use the service should expect to enjoy an improved environment in the near future. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Extensive improvements were being carried out to the interior of the building at the time of this inspection and the inspectors have given consideration and allowances for the environment and the changed routines and any disruption this may have caused. The manager stated that the whole of the ground floor was being redecorated and this included a considerable amount of replastering of the walls, rewiring the electrical circuit and providing a separate entrance to the manager’s office. Further environmental improvements are planned for the kitchen to be re-tiled and refitted, the lounges and bedrooms to be repainted and the entire floor to be laid with suitable covering. The Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 18 responsible individual had previously informed the inspector, that a grant had been received from Cambridge County Council for these environmental improvements. The home employs two cleaners and one cleaner was working during the inspection. On the day of inspection the redecoration was planned to take place during the morning, so that people were only minimally affected. This plan was to allow the staff and people access to the upstairs in the afternoon. This plan was kept to and was managed well. There were areas of the home where the carpet was loose near to doorways because the grippers had been removed and these presented a potential hazard. One area of torn carpet was preventing a fire door from closing automatically in the dining room and this was corrected during the inspection, after the inspectors pointed it out. During the afternoon the inspectors informed the manager that the bathroom on the upper floor had a used and dirty toilet and sink. The sink was also cracked. This is a bathroom that is not usually used because of the state of repair and there are sufficient bathrooms in the home without this one. The hot water temperature in the other upstairs bathrooms was found to be very hot and was reported to the manager during the inspection. The hot water temperatures had been recorded at 65 and 67 Celsius. On the day of inspection the central heating was on and the house felt very warm. The feelings of people living in the home were not solicited (by inspectors) in this matter and it is accepted that the home must be kept warm enough for frail and less active people. The radiators were very hot to the touch although they were very well protected and covered and service users were protected from their heat. There was only one window that was opened (and was restricted) in the home and this was an upstairs bathroom window. There were individual areas of the home where there were slight odours of stale urine and one of these was attended by the cleaner during the inspection. An uncovered used commode was noticed in one shared room on the ground floor. The toilets and bathroom had cotton towels for drying hands and no paper or disposable towels. Liquid soap was provided. An open laundry basket containing dirty clothing was in a corner of the ground floor corridor. It was considered that there is a risk of cross infection and this was discussed with the manager. The manager was invited to consult with a Health and Safety officer, if she felt this would help and as an Environmental Health officer had recently assessed the premises. Keneydon House DS0000061370.V338315.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, Quality in this outcome area is adequate. Staffing numbers are limited and recruitment is not rigorous enough to assure safe recruitment processes are always followed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A total of 16 people are employed by the home, including the manager, twelve of whom are care assistants. During the inspection there were two care assistants, a cook, a cleaner, and the manager working and 19 people living at the home. The staff roster showed this as correct. Some of the staff had not been listed for their different roles, such as cook, cleaner and care assistant. The manager stated she would list the staff so their differing roles and working times will be identified. The manager did not appear on the roster and agreed to be included in the future. The manager stated that in addition to two care staff, another care assistant works from 10am to 5pm, although the roster showed this was not a consistent, or everyday arrangement. The manager stated that she works as a care assistant when necessary and this was not shown on the roster. Considering the upheaval caused by the redecorating in the home and the responsibilities expected of a manager, there were minimal care staff working. People were observed sitting alone without care assistants Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 20 being present. However, no immediate or adverse outcomes were reported or noticed during the inspection. The last report on 23rd May 2006 found the staffing outcomes good. This inspection revealed that recruitment processes were not so complete as they had been. The files of two recently employed care staff were assessed. One person commenced employment in February 2007 and had a satisfactory POVA first check, a personal reference, but did not have an employment reference or a copy of the letter requesting a reference, or a CRB disclosure. The manager stated that the responsible individual had telephoned her to inform her that the CRB had been received although there was no record or disclosure number quoted. Employment gaps had not been explained and there were not any interview notes. Written one-to-one supervision notes had been recorded, but there was no reference to the shadow working arrangements that the manager said had been arranged. Another care assistant, who started work in May 2007, had interview notes on file and one written reference. The manager stated that a telephone reference had been requested, although this had not been recorded. Neither files contained letters of confirmation of employment. Peterborough Primary Care Partnership have provided an induction training programme and staff at the home had attended this and the most recent employed care worker was due to attend shortly after the inspection. The training records were not accurately maintained; there were missing course dates for training that had been provided that did not match with some of the training certificates that had been received. It was discussed with the manager that the records were not accurate and therefore the information kept about training and training arrangements was unclear. Some training topics had been recorded as being provided in 1998, 2000 and 2001, may need to be revisited and re-provided for care staff. All staff except two had completed NVQ level 2 awards. Adult abuse training had been provided to all staff except the most recent member of staff. Refresher courses were being arranged for Moving and Handling. Keneydon House DS0000061370.V338315.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): 31,33,35,37,38 Quality in this outcome area is adequate. Record keeping can be improved so that service users are better protected from hazards and risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is eager to assist service users and leads by example. She is keen and willing to ensure the safety of people living at the home and has created a friendly relaxed atmosphere for staff and for service users. There are aspects of recording that are the registered manager’s responsibility that have already been mentioned in this report, such as writing risk assessments and applying these to care plans; ensuring training records and arrangements Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 22 are accurately maintained, ensuring that the correct recruitment documentation has been obtained and ensuring that supervision arrangements for new care workers is recorded. Relatives and “residents’ meetings” continue to be arranged. Consultation with one relative about the care plan was a good inclusive aspect of involving this person in her husbands care arrangements. The home does not manage service users finances. Fire drills and fire safety equipment checks are arranged and electrical testing for portable appliances and for the building is due for renewal. Regulation 37 and Regulation 26 reports were read. These had noted the number of falls. The manager is recommended to keep a specific falls register in addition, as recommended by Cambridgeshire PCT falls prevention nurses, in addition to the accident and incidence book so that all falls can be monitored and assessed for any preventative action. Keneydon House DS0000061370.V338315.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X N/A X 2 2 Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13(4)(c ) Requirement Risk assessments must be made for each person living in the home to ensure that known and unnecessary risks to their health and safety are identified and can be eliminated or reduced by an action plan. Medication Administration Records must record the amount as well as the type of medication people bring with them when they move into the home so that they are safeguarded by the accuracy of the homes medication records. The manager must ensure the home has a written adult abuse policy and procedures. Hot water temperatures must be controlled so that people who live in the home and staff are not at risk from hot water. The risk of infection and contamination in bathrooms and toilets and by unwashed clothing must be assessed and action taken to minimise any risk. Staffing levels must be reviewed so that people who use the DS0000061370.V338315.R01.S.doc Timescale for action 01/08/07 2. OP9 13(2) 25/05/07 3 4 OP18 OP25 13(6) 13(4)(c) 01/08/07 01/06/07 5 OP26 13(3) 01/07/07 6 OP27 18(1)(a) 01/07/07 Keneydon House Version 5.2 Page 25 7 OP29 8 OP38 19(1) (a)(b)(c) & Schedule 2 13(4) (a)(c) service are continuously provided care by sufficient numbers of care assistants. Recruitment procedures must ensure that people living at the home are safeguarded by checking the suitability and fitness of care workers. A risk assessment must be made so that the refurbishments being undertaken in the home are assessed for all hazards and unnecessary risks are identified and eliminated so that all people in the home are safeguarded. 01/07/07 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. No. 1. 2 3. 4 Refer to Standard OP18 OP25 OP26 OP37 Good Practice Recommendations The contact telephone numbers for reporting an allegation of abuse should be made easily visible to all people visiting or living in the home. It is recommended that windows be opened at times and in areas assessed as safe to improve ventilation. The manager should consult with the Health and Safety Officer for guidance on risk and prevention of cross infection. The manager is recommended to keep a specific falls register so that all falls can be monitored and assessed for preventative action. Keneydon House DS0000061370.V338315.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Keneydon House DS0000061370.V338315.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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