Inspection on 28/09/05 for Kenilworth Grange

This inspection was carried out on 28th September 2005.

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

Other inspections for this house

Kenilworth Grange 20/02/07

Kenilworth Grange 01/02/06

Kenilworth Grange 15/11/04

Kenilworth Grange 16/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Kenilworth Grange Spring Lane Kenilworth Warwickshire CV8 2HB Lead Inspector Sandra Wade Unannounced Inspection 28th September 2005 09:30 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 Kenilworth Grange DS0000004328.V253322.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. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kenilworth Grange Address Spring Lane Kenilworth Warwickshire CV8 2HB 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) 01926 863320 01926 863310 Trinity Care Limited Ms Margaret McAtamney Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60) of places Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2004 Brief Description of the Service: Kenilworth Grange is a purpose built sixty bed care home which is registered to provide care for elderly people. The home has three floors, the top floor provides twenty beds for those who require residential care. The ground and lower ground floors accommodate up to 40 people in three units who require nursing care. All bedrooms have en suite facilities and are for single occupancy. Shared lounges and dining rooms are available on each floor and there are communal bathrooms and toilets for residents’ use. There is a passenger lift to each floor as well as the main staircase. There are large gardens, which are accessible to all residents, and there is ample car parking to the front of the building. Kenilworth town centre is close by with all the usual amenities. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced and was undertaken by two inspectors between the hours of 8.20am and 8.10pm. The inspection process included a tour of the home, talking with the Manager, examining care plan records, discussions with staff and residents and a review of policies and procedures of the home. What the service does well: What has improved since the last inspection? What they could do better: Residents’ care plans need to contain more detail in order to avoid an oversight of residents’ needs. The systems for storage and administration of medicines need to be improved in order to protect residents from harm. The staff that are available for each individual unit are not confirmed in duty rotas for each unit. Although a duty rota was available for the “Willow” unit there were not individual rotas for other units which would help to confirm the staffing arrangements in place and confirm responsibilities. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 6 Staff working in excess of their contracted hours and long shifts continues to require monitoring to ensure this does not impact on their effectiveness. 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. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents have their needs assessed before being admitted to the home so that staff know what care is required to meet their needs. EVIDENCE: This home hold computerised care records as well as paper records for each resident. A detailed assessment form is available for all information required to assess prospective residents’ needs prior to moving into the home. The manager told the inspectors that prospective residents are visited to complete the assessment of their needs prior to their admission. Consideration is given to health, personal and social needs during the assessment and the information gathered forms the basis of the care plan to meet the needs of residents. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 9 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): Standards 7,8,9 and 10 were assessed Residents’ care plans contain insufficient detail of the actions required to meet residents’ needs and are not consistently reviewed which may lead to an oversight of care. Residents have access to health care and relevant health professionals to ensure their health needs are met. The systems for storage and administration of medicines are not robust enough to ensure that residents are protected from potential harm. Residents are treated with dignity and respect which will have a positive impact on their self esteem. EVIDENCE: Residents spoken were generally positive in their comments regarding the home and the care provided. Care plans are in the process of being transferred from computer records into written records and it was evident that some of the information held on the Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 10 computer files, which staff said they are working to, conflict with the written records. Information provided by staff in regard to the behaviour and psychological needs of a resident was not fully reflected in the care plans in place. Although there was instruction for staff to monitor any aggressive episodes, it was not evident in the daily records that the psychological aspects of this residents care were being recorded consistently. The communication care plan did not make it clear as to the level of communication this resident had. It was clear on observing this resident that communication was limited. It was not evident that their activity assessment had been completed and it was explained that this is an important aspect of this residents care due to the care needs identified. It was apparent from viewing the records for this resident that due to their irregular sleep patterns there were occasions when they were missing meals. A nutritional care plan was in place for this resident but there were no actions indicated to address this such as giving snacks and drinks between meals to ensure they were receiving sufficient nutrition. Other care records viewed for nursing residents did contain risk assessment tools for monitoring nutrition, falls, moving and handling and tissue viability and these had been regularly reviewed. Residents had been weighed regularly and the nutritional intake of those residents with nursing needs at high risk of losing weight, had been recorded. A care plan in place for personal care stated that a resident required assistance from staff but it was not clear on bathing or showering arrangements. This was documented in a separate file. The separate file confirmed the resident had chosen specific days to have a bath. The records in place did not demonstrate a bath was being given on the days allocated consistently and it was not evident that this was something the staff were monitoring to make sure the resident was being bathed regularly. Daily records were noted to contain short statements such as “settled morning” or “quite night” which does not give a report as to the care the resident has received. Staff should be recording care given in regard to the care needs identified in the care plans. Staff were observed to knock doors during the inspection process and were respectful to residents. The call bell was observed to be answered promptly when a resident used it during a discussion with the inspector. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 11 Arrangements are in place to enable residents to see the optician, dentist and chiropodist as these health professionals visit the home. All residents are registered with a GP and have access to hospital consultants through out patient visits or domiciliary visits. Residents living in the residential unit of the home do not receive nursing care from the nursing staff employed at the home but are visited by district nurses for changes to wound dressings or to administer insulin. Medicines are administered by Registered Nurses in the nursing care units of the home and by senior care staff in the residential unit. Medication Administration Records (MAR) were found to be complete. Concerns about the receipt, recording, storage, handling, administration and disposal of medication were found during the inspection. A prescribed cream for a named resident was found in the bedroom of a different resident. Medication records should record details of how medicine is to be administered and the term ‘As Directed’ should be avoided. Eye drops stored in an appropriate drug fridge were not dated to indicate the date of opening, which would ensure that they were not used beyond the time period stated. During an audit of the medicines of two residents there were two incidences where administration records did not correlate with the number of tablets in the home. This suggested that tablets were not given although staff had signed to state they had been administered. A complete audit of controlled drugs was made and the number tallied with records held in the home. One nursing care resident self administers some medication but this was not recorded on the MAR sheet and an appropriate risk assessment had not been completed demonstrating this resident was could safely administer their own medication. The current systems for the disposal of medications were discussed and concern was raised in regard to the storage system of these until they are collected for disposal. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Residents receive a varied diet in pleasant surroundings but this is not always to the full satisfaction of the residents. EVIDENCE: It was clear from discussions with residents that there were mixed views in regard to the food. Some were happy with the food provided and others were not. Both inspectors joined the residents for lunch on different units to sample the food. It was observed that those residents who had a lamb dinner found it difficult to cut the lamb and some commented it was tough. Some residents said that they had told staff before when given lamb that it was tough. It was noted that several plates went back to the kitchen with some of the lamb still on the plate. Those who chose the jacket potato were seen to receive a small to average size jacket potato with cheese or a prawn a filling which did not look like a substantial meal although those that had chosen this enjoyed it. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 13 One resident was given a low fat yoghurt and preceded to add sugar to it stating “I am putting back in what they have taken out”. On viewing yoghurts in the kitchen later in the day it was clear that there were alternative full fat yoghurts available. Those residents who enjoyed a cooked breakfast or a hot choice at breakfast complained that they had to wait too long for it to arrive and one stated, when it did, sometimes it was cold and staff would warm it up in the microwave. A resident said that this was because it had to come from the main kitchen as opposed to being prepared in the kitchenettes available on the units. During the lunchtime period it was clear that meals served on the top floor took a long time to serve resulting in each table eating at different times. It was evident that some concerns received by the manager in regard to food had been followed up and addressed but it would seem that not all residents remain satisfied with the quality of the food provided. The meeting notes for July confirmed that food had been discussed but it was not clear which residents attended and how many had given their views on the food. There are still staff who have not completed the basic food hygiene training and this remains an issue outstanding from the last inspection that is to be addressed. Menus indicate that snacks are provided but staff confirmed they are only given if residents ask for them as opposed to having a tray of sandwiches or snacks which are offered. Staff reported that it tended to be the same residents who would have snacks in the evening. Several residents were noted to require assistance with their food and some had swallowing difficulties so thickening agents were being added to the fluids being given. The fridge in the kitchenette on the ground floor was found to be dirty and jam in a dish was not labelled or dated to say how long it had been in the dish. Something was wrapped in foil which also was not labelled or dated and the freezer section of the fridge was heavily frosted. The microwave was dirty. In the main kitchen the microwave had a sign on it stating it was out of order but it was established this was not the case and the microwave was working. The floor and big sink was dirty and had the appearance of being tea stained. One of the fridges was not working and the freezer was heavily frosted. A portable fan in use was resting on a work surface and was noted to be in need of cleaning. The work surfaces had the appearance of being wiped with a dirty cloth Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 14 Pasta and semolina in the food store had been sealed with a clip as opposed to be stored in an airtight container to keep the food fresh and pest free. An open packet of Jelly crystals were in a container with no lid. The hand wash sink contained a saucepan of eggs, this should be kept free for staff to wash their hands. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Complaints received are listened to, taken seriously and are acted upon. EVIDENCE: A complaints procedure is in place and is detailed in the Service User Guide which is made available to residents in the home. The manager had taken action to record any concerns received in the complaints book and since the last inspection has recorded eight concerns. Four of these were linked to food which the manager stated were all upheld. Out of the other four complaints two were upheld, one of these was linked to the moving and handling of a resident. It was evident that the manager had taken these concerns seriously and had taken actions to resolve them. It was advised that in addition to the records currently kept, the manager also clearly states whether they have been upheld or not upheld. No formal complaints have been received by the Commission in regard to this home. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,25,26 Generally the premises are well maintained resulting in a suitable living environment for residents. Sufficient numbers of toilets and washing facilities are available and the environment is safe and comfortable for the residents. The home on the whole is clean but some actions are required to ensure cleanliness is being maintained in all areas. EVIDENCE: The home has three floors, the top floor provides twenty bed residential unit for residents who do not require nursing care. The ground and lower ground floors consist of three units which provide nursing care. On each floor there is a spacious lounge/dining area and kitchenettes are available to three of the four units so that staff can prepare snacks and drinks without reliance on the main kitchen. The home on the whole was found to be clean and well maintained and the manager advised that the lounges and some of the bedrooms had recently been redecorated. The carpets in the corridors were marked and looked in Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 17 need of replacement. The manager advised that had been included as part of the refurbishment plan for the home. Since the last inspection action has been taken to indicate more clearly within records those residents who do not wish to have a key for their room. All bedrooms have en suite facilities and there are also communal toilets available on each floor. In addition the home have four communal showers and four communal bathrooms with assisted facilities to help the less mobile. It was evident that there is limited space within the home for storing equipment. During the tour of the home a wheelchair was being stored in an assisted bathroom and a hoist was being stored in front of one of the shower rooms which needed to be removed each time this room was used. A toilet roll holder was broken in one of the shower rooms and the shower head in the shower room on the ground floor was broken. The walls of the bathroom on the ground floor and top floor were scuffed and the manager advised plans were in place to address this. Two of the ensuite bathrooms in residents rooms on the lower ground floor were noted to have an unpleasant odour and one of these had limited storage space for toiletries. The home is well ventilated and all heaters are of the low surface temperature type to prevent any burn risks to the residents. The temperature in the home on the day of inspection was warm and comfortable. A number of hot water outlets were tested and water was found to be within safe levels to that there were no risks of residents scalding themselves. Suitable facilities are in place for sluicing and maintaining good infection control within the home including a washing machine with a sluice cycle and 4 separate sluice rooms with commode pot washers. One of these was found to be out of order and staff confirmed it had been reported and they were waiting for it to be repaired. It was noted that supplies of gloves and aprons were not available in sluice areas to ensure good infection control practices can be followed. It was not evident that the home has received a water inspection to confirm the home is operating in compliance with the Water Supply (Water Fittings) Regulations 1999. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The staffing of the home is sufficient but records do not always demonstrate this consistently. Staff training is being provided on an ongoing basis but further work is required to ensure training standards are being fully met so that staff are trained and competent to do their jobs effectively. The homes recruitment policies and procedures are appropriate to support and protect the residents from harm but these are not always being followed. EVIDENCE: Staffing is arranged in accordance with the needs of the residents. On the top floor where there are 20 residents, the home aim to have three carers from 8 – 2pm and two carers from 3 – 8pm and two waking night staff. The nursing units are supported by two nurses, one covers the 12 bed unit and the 13 bed unit on the lower ground floor and the other nurse covers the 15 bed unit. The nurses are then supported by three carers on the 15 bed unit and two carers each on the 12 and 13 bed unit. This leaves one carer floating to assist wherever they may be needed the most. In addition to the manager who works supernumerary to the staffing numbers, there is a deputy manager who works as part of the nursing shifts. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 19 On the day of inspection the home was found to be suitably staffed with nurses and carers in accordance with the dependency of the residents. However, the duty rota for night staff and day staff does not clearly state the shift patterns worked i.e. they state “E” or “L” or “E/L”which are not defined and it is therefore difficult to establish the actual hours being provided. The duty rotas show that the majority of staff are working early shifts followed by a late shift, some staff are working in excess of 3 or 4 days per week on this shift pattern which means they are working long hours that could impact on their effectiveness. It was noted from one duty rota that a member of nursing staff is working day shifts as well as night shifts and had worked a night followed by a late shift and another night. This is not considered good practice as there is a short break between shifts which could affect the effectiveness of the nurse. Duty rotas seen do not make it clear which nursing staff and which care staff have been assigned to each unit or who the “floater” carer is. The shifts/hours that the manager is working are also not indicated so that the actual number of supernumerary hours being provided can be confirmed. In addition to these staff, the home is supported by two cooks, one head cook and one assistant cook who provide cover seven days a week from 8am till 7pm. There is a housekeeper and 4 cleaners who provide support six days per week. The inspector was advised that light cleaning is covered by carers on Sundays. Duty rotas do not confirm the amount of care hours allocated to this duty. A laundry person is employed to work four days per week and the Housekeeper also assists with this. The duty rota confirms that there are no staff identified to cover the laundry on Sundays. The manager has confirmed that there are 49 care staff employed and out of these six have achieved an National Vocational Qualification (NVQ) II in Care. The care standard relating to NVQ training stipulates that the home should have 50 of their staff with an NVQ II by 2005 so that care staff are suitably trained to provide effective care to the residents. Statutory training is being addressed on an ongoing basis but actual numbers of those staff who have and have not completed the training could not be established as training information is held on each individual staff file. Since the last inspection, action has been taken to access dementia care training for staff as required. Staff files were reviewed and these were noted to contain most of the required information. It was not always clear from reference information that these were from last employers or in what capacity the referee knew the applicant. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 20 Original Criminal Record Bureau (CRB) checks are not held on files to confirm any criminal offences or Protection of Vulnerable Adult Checks undertaken. This information should be available to confirm the home have taken appropriate action within their recruitment practices to safeguard residents. One file did not contain information to confirm the person was both physically and mentally fit to carry out their role and one file did not document the employment start date. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36,37 The home is managed by a dedicated and effective manager who is able to discharge her responsibilities fully. Systems are in place to enable the residents to have a say in how services and care are provided. Staff are being supervised to monitor their competencies and to ensure they are providing effective care and services to the home. Some record keeping within the home is in need of review so that the home can demonstrate they do what they say they do. EVIDENCE: The manager is a qualified nurse and since the last inspection has secured funding to complete the Registered Managers Award which she has just started. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 22 It was evident that the manager has been attending various training courses to update her knowledge, skills and competence to continue to manage the home effectively. The manager holds regular meetings with residents/relatives so that issues relating to the home can be discussed and residents can have an opportunity to have their say in how the home is run. The notes of a meeting held in September confirmed that catering, housekeeping, transport arrangements, staffing changes, home refurbishment and fire drills had been discussed. The meeting notes confirmed improvements implemented in regard to issues raised by residents. This included the use of new trays throughout the home and varying flavours of ice cream being provided. It was advised that meeting notes make it clear who has attended each meeting and include fuller details of suggestions and ideas raised as it was not always clear that actions had been taken as a result of an issue being raised. Discussions with residents and relatives were positive in regard to the staff and the care provided. The only negative comments made were in regard to catering services some of which are detailed in standard 15 above. Quality questionnaires are in use within the home but a recent survey has not been carried out. The manager advised there were new surveys now available which she would be sending out. It was noted that the inspection report was not on display in the home and the manager was advised to take action to address this so that visitors and residents could read this if they wished. Arrangements are in place for staff supervision and this is organised so that the manager undertakes formal supervision sessions with the Heads of Departments such as the cook, housekeeper etc, the Deputy Manager undertakes supervision with the nurses and the nurse undertake supervision with the carers. The current format for supervision was discussed with a view to making this more focused on the policies and procedures of the home. The manager advised that new supervision schedules were due to be implemented. The scheduling of dates was discussed so that each member of care staff receives supervision 6 times per year. Records reviewed as part of the inspection process are detailed in each section within this report. Areas where further work is required to improve records are detailed in the requirement section at the end of this report. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 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 X 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 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X 2 X X X 3 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 3 2 X Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 OP7OP37 Regulation 15 (1) 12 (1) (a) Requirement The manager is to confirm that the transfer of computerised care plan records into written care plan records has been completed so that staff are working to one clear record. Care plans must demonstrate the psychological care needs of residents and staff actions required to address these. (issue from last inspection) Daily records must demonstrate the staff actions carried out to meet the care needs identified. Communication care plans in place need to contain sufficient information to make clear any communication problems the resident may have and how staff are to address this. Nutritional care plans must state specific actions staff are to carry out to maintain a residents nutrition effectively if residents miss meals due to poor health or sleep patterns. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 25 Timescale for action 30/11/05 “ “ “ “ Records relating to personal hygiene such as bathing must demonstrate that a residents hygiene is being maintained effectively. 2 OP9 13 (2) The registered manager must ensure that nursing staff adhere to safe practices when administering medication to residents in their care. Nursing staff must ensure that they are aware of the Nursing and Midwifery Council guidance on the safe administration of medicines. The concerns identified in this report, on the management and administration of medications must be addressed, within a risk management framework. Prescribed creams must only be used for the person they have been prescribed for. 3 OP15OP38 16 (2) (4) 12 (3) The registered person shall having regard to the size of the care home and the number and needs of service users provide, in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared and available at such time as may reasonably be required by service users To fully demonstrate the above, menus are to be reviewed to include snacks and drinks and a supper time menu which can be taken after the main meal in the evening. Ongoing monitoring of food being provided is required to Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 26 30/11/05 30/11/05 ensure this is to the satisfaction of the residents. Food kept in the refrigerator must be appropriately wrapped, labeled and dated. All areas within the kitchen and kitchenettes must be maintained in a clean condition consistently. Dried foods that have been opened must be stored in sealed containers. The manager must ensure that all staff handling/cooking food are complying with food hygiene and infection control legislation and guidance. Training is to be arranged as appropriate. (Issue from last inspection). 4 OP21 23 (2) (l) Suitable storage facilities are to be identified for wheelchairs so that they are not stored in bathrooms. The broken toilet roll holder and shower head as identified during the inspection are to be repaired. Confirmation is required of a date to repaint the bathrooms/shower rooms as appropriate. 5 OP26 13 (3) 16 (2) (j) Unpleasant odours identified in the two ensuite bathrooms on the lower ground floor are to be removed with immediate effect. A date for the sluice machine to be repaired is to be confirmed. Gloves and aprons need to be available in the laundry and Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 27 30/11/05 30/11/05 sluice areas consistently. The manager is to confirm arrangements made to demonstrate the home complies with the Water Supply (Water Fittings) Regulations 1999. 6 OP27OP37 18(1)(a) 17(2) Sch 4 Duty rotas for the home must state the times of shifts being worked so that it is clear how many care hours and nursing hours are being provided. The managers hours must be indicated on the duty rota to demonstrate supernumerary hours being worked. Duty rotas must indicate the number of care hours allocated to non caring duties such as laundry and cleaning on Sundays. Duty rotas need to clearly indicate which staff are working on which unit so that there are clear staffing arrangements and support identified for each unit in the home. The manager must keep staffing levels under review, in particular the monitoring of staff working in excess of their contracted hours to ensure they are fit for duty. (Ongoing issue from last inspection). The manager must ensure that there are sufficient breaks between nursing shifts to ensure staff do not work long hours which could impact on their effectiveness. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 28 30/11/05 7 OP28 18 (1) (a) The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The manager is to confirm arrangements to ensure at least 50 of care staff achieve an NVQ II in Care as soon as possible. A list of all care staff who are to undertake this training is to be forwarded with dates for training to be completed. 31/12/05 8 OP29OP37 19 Recruitment practices are to be reviewed so that it is clear who references for staff are from and in what capacity they knew the applicant. Criminal Record checks must be available to confirm POVA checks and any criminal offences. Information must be available consistently to confirm staff employed are both mentally and physically fit to carry out their role. 30/11/05 9 OP30 18 (1) (a)(c) The manager is to forward an ‘at 31/12/05 a glance’ training schedule detailing the dates of training completed by all staff. This must include details of statutory training (including food hygiene), medication training and other training as appropriate to the needs of the residents. DS0000004328.V253322.R01.S.doc Version 5.0 Page 29 Kenilworth Grange Where staff have not completed statutory training within the required timescales, a date for training to be undertaken is to be indicated. 10 OP31 7, 9 The manager is to confirm completion of the Registered Managers Award as appropriate. 30/04/06 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 Refer to Standard OP9 Good Practice Recommendations It is advised that the current storage system for the medications that are to be disposed of is reviewed to ensure safe systems are in place for the disposal of medications. Staff should also maintain records of any medications disposed of in this manner. Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 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 Kenilworth Grange DS0000004328.V253322.R01.S.doc Version 5.0 Page 31 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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