Inspection on 08/04/08 for Keneydon House

This inspection was carried out on 8th April 2008.

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

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

Other inspections for this house

Keneydon House 07/04/09

Keneydon House 14/05/07

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 Unannounced Inspection 8th April 2008 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.V361920.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.V361920.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.V361920.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 14th May 2007 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 added 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 £395 per week and £445 per week depending on assessed needs. CSCI inspection reports are available at the home and can be accessed on the CSCI website. Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. An Annual Quality Assurance Assessment (AQAA) was returned by the service. Four ‘service user’ forms were returned with only tick boxes marked and no comments made. Four relative’s survey forms were also returned and they each indicated they were satisfied with the quality of care provided by the home. The CSCI carried out this inspection with two inspectors, Don Traylen and Janie Buchanan, on 8th April 2008. The inspection started at 10:15 am and finished at 3:30 pm. A cleaner, who is also employed as a care worker, accompanied the inspectors when they looked around the home at the start of the inspection. Most of the people living at the home were spoken to and two care staff were spoken to. Four people’s care plans were assessed and one person’s care was tracked. Medication records were read and the records for maintenance and fire safety were read, as were some of the home’s policies and procedures. Feedback was provided to the manager both during and at the end of the inspection. What the service does well: What has improved since the last inspection? Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 6 The home has demonstrated they are able to make improvements. Six of the eight requirements made at the last inspection on 14thMay 2007 have been met and the environment has been extensively improved since the last inspection. The redecoration of the entire ground floor area, apart from one bedroom, the four toilets, the kitchen and the managers office have been completed and have made a significant difference to the lightness and the brightness and feel of the home. New flooring, of either carpet or vinyl, has been laid throughout most of the in the ground floor area. The stairway to the upper floor has also been included in this refurbishment. A new chair lift has been installed. Although it is acknowledged there are still improvements that can be achieved, the management and staff have made a significant effort in bringing about significant improvements to the service. Care plans have been rewritten and have been re-presented in a typewritten, clear and tidy format that were easy to read and to understand. An activities worker had commenced work at the home the day before this inspection. What they could do better: One of the two outstanding requirements has been extended and the other has been incorporated into the requirement to prevent cross infection throughout the home. Where it is a necessary part of care to record a person’s fluid intake, individual fluid charts must be maintained and contain adequate detail, so that a clear and accurate record is kept of how much people drink. Other aspects of care plans that state what care should be provided, must be of a descriptive content so that care staff are able to follow this instruction. People should always be shown respect by knocking on their doors when entering their rooms. People living in the home should be consulted for their social and leisure interests and be given more opportunity for leisure and recreational activities outside the home, so they have access to fresh air, sun light and stimulation. Whist the home has an electrical test certificate for the new electrical wiring installed, they must ensure that all electrical wiring is safe. The home must ensure that the temperatures of hot water are safe. Maintenance of the property should continue to improve, so that people live in an environment that is safe and comfortable. A range of measures to Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 7 redecorate and refurbish the upper floor bedrooms, bathroom and hallway would further improve the internal environment of the home. The front of the home’s external environment is in need of general maintenance and repair. The flaking paintwork that is revealing rotten woodwork to the window frames should be repaired and the garage door is in need of repainting and possible repair. The complaints procedure should be made more easily available to residents so they know how to raise any concerns they might wish to express. The contact telephone numbers for reporting an allegation of abuse should also be made easily available and visible to all people visiting, or living in the home. Staffing levels should be increased so that people can participate in their choices about social and leisure interests. The management of health and safety at the home must improve so that residents are protected. Cleanliness must improve so that all residents live in conditions where any risk of cross infection is minimised. The home must ensure they have addressed the risks known to cause cross infection. Risks associated with potential cross infection noted during the inspection included: unclean commodes, the lack of suitable hand drying facilities in the communal toilets, an unclean tea trolley and teapot, uncovered food in the fridge and an open and unguarded external doorway from the kitchen. 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.V361920.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.V361920.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 considering moving into the home are always assessed prior to moving in and are given the opportunity to visit before making any decision. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of inspection there were 18 people living at the home. The admission details of one person were assessed. The person had arranged for respite care on a privately funded basis. Her assessment details that had been carried out by the home were undated and were not signed by the assessor or by the person assessed. The details of her needs were brief and were mostly shown as indicators of need. Cambridgeshire Primary Care Trust (PCT) funds most people living at the home and the PCT’s Care Managers had comprehensively assessed these people. Intermediate care is not provided. Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10, Quality in this outcome area is adequate. People are not assured their care plans are accurately recorded and reviewed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four people’s care plans were read. One person was observed to receive her care in bed. She had very limited ability to weight bear or to communicate verbally. She was dependent upon being fed and receiving fluids and was in need of being turned regularly to relieve pressure on her skin. The records for her fluid intake showed there were probably omissions and there were periods of 10 or 12 hours unaccounted for. Her care plans did not clearly indicate the plan to provide her with fluids and food or how this should be given and how frequently, or why. There was no written plan to state that fluids intake should be measured and recorded, although this was being undertaken. Her fluid chart did not show the actual amount of fluid she was being given, all that was written was ‘tea’. Her plan did not show the action necessary to relieve her Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 11 current pressure sore areas. Her plan did record that she needed assistance to feed and drink and had recorded her other needs, but not that she was mostly confined to bed and was to receive her care in bed. It stated that she was to be taken to the dining room for her breakfast and lunch, even though this was no longer the case. There was a daily routine that was a good indicator of her general routine, but it was not an accurate description of the needs and routine observed on the day of inspection. Her health care plans did not include a referral for nursing or a nursing assessment. On the day of inspection she had not been seen by, or visited by a Community Health Service Nurse. This person’s needs were immediately discussed with the manager who agreed to contact the Community Nurse. The manager also gave her assurance that the fluid charts would be accurately recorded with immediate effect. Another person’s care plan stated “asthmatic” and was also affected by Dementia. Her plan did not contain a record of what care was needed in relation to her asthma. The nutritional measurement tool in her care plan was last recorded in 08/09/2004. Another person’s plan read, “needs assistance and encouragement to eat” but did not describe what or how to encourage, or what assistance was needed and how it could be provided. Another person’s care plan recorded “high risk” in an assessment of her skin condition, but did not indicate a plan to meet this risk. In the care plans there was generally basic information about many needs that did provide care assistants with adequate information of how to give care. Daily routines were recorded as useful references to “preferences” and “dislikes”. The plans we looked at showed very little evidence that people had been actively involved in planning and reviewing their care. Although plans had been reviewed monthly, often all that was recorded month after month was “no change” in the resident’s needs. Medication administration records were accurately recorded. People we spoke to told us staff treated them well and understood their needs. We observed one member of staff enter one person’s bedroom without knocking first, or announcing herself. The doors in two toilets adjacent to the lounge in the ‘annex’ area could not be locked and did not provide privacy when in use. These two issues regarding privacy were reported to the manager during the inspection. Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, Quality in this outcome area is adequate. People are assured they can lead a quiet and peaceful life at the home, although people wishing for stimulating activities are not assured they will be provided. People are not assured staffing levels allow them to them to reasonably pursue their leisure and social interests This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has recently appointed a specific member of staff to organise activities for two hours a day, five days a week. We met this member of staff who appeared enthusiastic and had good ideas for both group and individual activities that she intends to promote. People that we spoke to told us that the staff were good and that they enjoyed the food at the home. One person said the home, “is very good” and that she didn’t have to wait too long for assistance. Another person said, “I get well looked after....I would like to get out more, anywhere”. However, one person Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 13 reported that she sometimes has to wait a long time for help and another stated that she would like to get outside a lot more often. One person told us that she greatly enjoyed an outing to Skegness, but that this was well over a year ago and she would like to go out more often. She told us that staff didn’t have the time to take her out, so she didn’t ask. The numbers of staff working at one time, which were two care workers and the manager, indicated there are not sufficient care workers at one time to allow people to be escorted or taken out of the home. There was little activity observed during the inspection and most people were sitting in the lounges or in their rooms. ‘Residents and relatives’ meetings continue to be held. Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 14 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 good. People are protected by the home’s abuse policy although the arrangements for reporting an allegation should be extended to ensure greater protection for people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure advertised on the notice board in the entrance hall. However, it is in very small print and quite high up, therefore making it difficult to read for residents with sight impairments and those in wheelchairs. Residents we spoke to were not aware that the home had a complaints procedure but did report, when asked, they would talk to the manager if they had concerns. There was a satisfactory and recently written adult protection policy and a copy of the agreement to adhere to the joint protocols agreed in Peterborough and Cambridgeshire. The home did not have a system to record and evidence or count the instances of any allegation of abuse. The manager assured us that they had kept the individual records although these could not be found for the incidents and investigation details of abuse that had been investigated by Cambridgeshire County Council. The contact telephone numbers for reporting any allegation of abuse are not easily available for people living at the home, or for any visitor to the home, should they ever wish to report an allegation. Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 15 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): 19,21,24,25,26, Quality in this outcome area is adequate. People would benefit from further improvements to the cleanliness of the home and from further maintenance that is needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The environment has been extensively improved. The redecoration of the entire ground floor area, apart from two bedrooms, the four toilets, the kitchen and the manager’s office have been completed and have made a significant difference to the lightness and the brightness and feel of the home. New flooring, of either carpet or vinyl, has been laid in the ground floor area. The stairway to the upper floor has also been redecorated and is vastly improved. A new chair lift has been installed. The internal environment of the home can be further improved. A range of measures to redecorate and refurbish the Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 16 upper floor bedrooms, bathroom and hallway would further improve the internal environment of the home. The kitchen is in need of extensive refurbishment and refitting, which is stated as an aim in the AQAA as an improvement, planned for by the home. Environmental Health Officers have recently visited the home and made requirements for the home regarding this kitchen. New chairs and tables have been purchased for the dining area and new chairs have been obtained for the annex dining room. New carpeting had been laid in various rooms and corridors and the stairs. However, the following shortfalls were noted: • Areas of the home were lacking in cleanliness: there was a dirty and broken commode chair in room 6; the tea trolley was stained, dirty and full of crumbs and we found an unclean urine bottle in one of the upstairs toilets. The carpet in the upstairs bathroom was badly stained and dirty. It was also loose and worn in places causing a possible trip hazard to residents. Wallpaper was coming away from the wall around the sink and the sink basin was cracked. Piping was coming away from the wall and the grab rails around the bath and toilet were rusty. This same bathroom had a cracked sink, a toilet without a lid and no hand drying facilities The front of the home’s external environment is in need of general maintenance and some repair. There is flaking paintwork that has revealed the rotten woodwork of the window frames. The garage door has been poorly maintained and is in need of repainting and potential repair. The hot water temperatures in all the sink taps in people rooms and toilets were too hot. The maintenance worker recorded some hot water temperatures on the day of inspection at 63C, & 59C. In room 3, the electrical wiring was protruding from the wall next to a small water heater above a hand basin and water from the heater dripped on to the wiring when this was turned on. The manager was immediately shown this and agreed to decommission this electrical equipment. Whist the home has an electrical testing certificate for the new electrical wiring installed, they must ensure that all electrical wiring is safe. A fire door to the annex area on the ground floor was held open by a hook and had no automatic closing device and was labelled “keep closed”. Portable Appliance Testing (PAT) for electrical equipment had not been carried out recently for a number of items looked at. Cross infection risks were presented by the unclean commodes noted in different rooms, the lack of suitable hand drying facilities and lack of toilet paper and the dirty tea pot and the trolley used to provide tea to people throughout the day. DS0000061370.V361920.R01.S.doc Version 5.2 Page 17 • • • • • • • Keneydon House 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 good. People are generally assured they are in safe hands and the skill mix of staff can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of inspection there were two care assistants working plus the manager, two cleaners, one cook and the handyman/maintenance worker. A gardener and an activities worker have recently been employed. Two care workers are employed at night and the manager explained that one of these care workers roles is a ‘sleep-in’ arrangement so they can be called upon to work should there be an immediate need. This was the usual staffing compliment shown on the staffing roster record. The manager stated that she and the cook and cleaner are flexible carers. The AQAA submitted by the home showed 350 hours of care staff a week were provided in the week prior to 24/03/2008, which is equivalent to approximately 50 hours of care provided each 24-hour day by two care workers, the one or two night care staff, the manager and any extra personal care given by the cook or cleaner. At the time of the inspection there were eighteen people living at the home. We looked at the files for the most recently recruited two staff member and this showed that all appropriate pre-employment checks including a CRB had Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 18 been undertaken before they started work at the home. One had not received training in adult abuse and stated she had not received any training since recently starting work in January 2008. The manager later explained that training in adult abuse had been arranged for her. Staff training in Dementia care had been provided to most staff. Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 19 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): 31,33,37,38, Quality in this outcome area is adequate. People’s best interests could be better secured by management attention to reducing risks from cross infection and to maintaining a clean and safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It is recommended the manager make arrangements for appropriate training so that better assessments to be recorded for people considering to self- fund their care. This has already been referred to in ‘choice of home’ outcomes in this report. Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 20 We discovered a number of risks to residents’ health and safety including the following: • • • • Food storage in the home was unsafe and we found undated and uncovered foodstuffs in the main kitchen fridge The fire door in bedroom no 6 did not close properly and the fire door marked keep closed leading from the annex area was held open by a hook Water in many of the bedroom sinks is very hot putting residents at risk of scalding themselves No water temperatures had been recorded in the home since September 2007. Temperatures previously recorded showed that the water regularly exceeded safe measurements, yet nothing had been done to address this. During the inspection the maintenance worker started to check and record the hot water supply. These showed temperatures of upper 50 and 63 C. This high temperature was verified by the inspectors who also tested the temperatures in many toilet sinks and in some of the bedrooms with sinks. We found hand towels in many of the communal toilets and bathrooms, thereby compromising good infection control No portable appliance testing had been undertaken at the home in the last year. The water heater in room number 3 was very dangerous with water leaking onto the exposed electrical wiring A recent report (20/02/08) by the Fenland District Council EHO officer highlighted numerous areas of concern in the kitchen and recommended a new ventilation system, cleanable wall surfaces and the elimination of surface electrical ducting be implemented • • • • These shortfalls put people at unnecessary risk. Cross infection risks were presented by the unclean commodes noted in different rooms, the lack of suitable hand drying facilities and lack of toilet paper and the dirty tea pot and the trolley used to provide tea to people throughout the day. The manager responded immediately during the inspection and worked hard to put right many of the shortfalls we noted, including checking the fire doors, requesting the maintenance worker to re-check the hot water temperatures, although these were still too hot; implemented new fluid charts and contacted the Community Nursing team. The home supplies meals in the local community and this service uses the kitchen resources of the home. This additional demand increases the workload of the cook and the use and storage facilities of the kitchen. It was disappointing to read in the AQAA that the home stated their ability to improve and invest in the environment would be adversely affected because of the small increases in the amount of funding offered by the local PCT. Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 21 Regulation 26 reports were not available at the home for January, February or March 2008 although the AQAA stated these are discussed with the home and kept at the home. The annual servicing of the newly installed boilers was planned for the day following the inspection. Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 X X 3 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X 2 2 Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2) Requirement Care plans must contain accurate, detailed and current instruction and information about how people’s care should be provided, so people are not at risk of not being given the care they need. Referrals to community Health Services for their assessment of the person’s needs must be made whenever the home is aware that any person has pressure on skin areas, so that people receive the healthcare support they need. Hot water temperatures must be controlled so that people who live in the home and staff are not at risk from hot water. The timescale for this requirement to be met has been extended. The home must ensure they have safety tested electrical wiring and electrical equipment, so that all people in the home are safe. The home must ensure that the risk of poor hygiene control and DS0000061370.V361920.R01.S.doc Timescale for action 01/07/08 2. OP8 13(1)(b) 01/05/08 3. OP25 13(4)(c) 01/07/08 4 OP25 23(2)(b) (c) 01/08/08 5 OP26 23(2)(d) 01/07/08 Keneydon House Version 5.2 Page 24 6 7 OP37 OP38 26 23(4) causes of possible cross infection are prevented, so that people are safe. Regulation 26 reports by the 01/07/08 registered provider must be carried out. The Fire Safety Officer must be 01/07/08 consulted regarding the fire door that is held open so that people’s safety is assured. 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 OP16 OP27 OP30 OP38 Good Practice Recommendations The complaints policy details should be at an appropriate eye level for people living at the home to read. Additional staff should be used to help people pursue their leisure and social interests The home should consider providing training in making assessments of need, so that they can improve their ability to assess and record people’s care needs. The manager should consult with the Health and Safety Officer for guidance on risk and prevention of cross infection. Keneydon House DS0000061370.V361920.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection CPC1 Capital Park Fulbourn Cambridgeshire 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. 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