Inspection on 08/08/06 for Kent House

This inspection was carried out on 8th August 2006.

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

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

Other inspections for this house

Kent House 10/10/07

Kent House 30/01/07

Kent House 04/10/05

Kent House 10/05/05

Kent House 17/02/05

Kent House 28/09/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Kent House Fairfield Manor Fairfield Road Broadstairs Kent CT10 2JY Lead Inspector Brenda Pears Key Unannounced Inspection 8th August 2006 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 Kent House DS0000023456.V301239.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. Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kent House Address Fairfield Manor Fairfield Road Broadstairs Kent CT10 2JY 01843 602720 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) Choicecare 2000 Limited Mrs Cathleen Langley Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th January 2003 Brief Description of the Service: Kent House is a detached Home with accommodation for residents provided on three floors. The Home is situated on the outskirts of the town in a residential area close to schools, local supermarkets and also on a local bus route. The home is registered for 25 older persons, there is a shaft lift and two small lounge areas, plus a dining room and a large conservatory to the front of the building providing an additional light and bright lounge area. The fees for support from the home are set during the assessment period and are very individual to the needs of the service user, depending on the level of support required and the staffing numbers provided. The current fee levels on average range from £303.00 to £448.00. Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection and the inspection process consisted of speaking with the manager, staff members and service users. The methods of inspecting the home included checking records, tracking service user care plans, examining staff files, observations and a tour of the building. The inspector spoke to six service users individually and also others in a group during this inspection. The inspection focused on the requirements from the last inspection and also on the core standards that must be covered in the inspection year. As part of the pre-inspection process, residents and relatives were consulted for their views of the home. These comment cards provide valuable feedback about the home, which helped in the planning of this inspection. Responses were received from one care manager, four service users and seven family/visitors. What the service does well: The home was found, in the main, to be clean and bright with a welcoming atmosphere. Service users expressed their confidence in the acting manager and stated they are comfortable to approach her, or staff, with any problems or requests. Discussions and questionnaires received also confirm that staff do support service users in an appropriate manner with due consideration for choice and dignity. These factors also confirm staff do provide appropriate care and support for those living in the home. One comment was ‘we are extremely happy with the care’ and another person has been ‘looked after extremely well’. Two responses to questionnaires stated there was not full awareness of the complaints procedures in the home or where to access an inspection report. The manager stated she would ensure people are made more aware of procedures and reports. However, a copy of the complaint policy is on display and is also contained in the Service User Guide that is in each service user room. Photographs are on display in the main hallway showing the D Day celebrations that were enjoyed in the home. One questionnaire received has described this as ‘a very enjoyable day’. Service users and staff dressed up for this occasion and photographs show a very successful day. Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kent House DS0000023456.V301239.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 Kent House DS0000023456.V301239.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Visits are undertaken and information is given to service users prior to admission, fully supporting any decision that is made. There are pre admission assessments on record though these are not always easily found. This supports the needs of new service users entering the home. The home does not specifically undertake intermediate care, but all appropriate support is given to enable a service user to return to their own home. EVIDENCE: Records sampled at this time contained contracts, terms and conditions and full pre admission assessments. Kent County Council assessment of care needs were also on relevant files with the assessments undertaken by the home. Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 10 All admissions to the home are supported with appropriate healthcare and assessed equipment is obtained prior to admission. One service user stated that information from Kent House was very good prior to admission and other questionnaires also supported this statement. One service user statement also described multiple visits being undertaken prior to admission to the home. A copy of the Service User Guide is available in all service user rooms. Kent House DS0000023456.V301239.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual care plans are in place but a sampling of files showed that these records are often muddled and information is not easily accessed. This does not ensure staff are providing care appropriately and may leave service users at risk. Staff do ensure healthcare needs are met, consider the dignity of service users and treat individuals with respect. Medication procedures are appropriate and a policy is in place, however, the home must ensure this fully reflects the routines and practices of the home. This will then ensure full support for staff dispensing medication and support the safety of service users. EVIDENCE: Service users expressed their confidence in the acting manager and stated they are comfortable to approach her, or staff, with any problems or requests. Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 12 Discussions and questionnaires received also confirm that staff do support service users in an appropriate manner with due consideration for choice and dignity. These factors also confirm staff do provide appropriate care and support for those living in the home. One comment was ‘we are extremely happy with the care’ and another person has been ‘looked after extremely well’. Discussions were undertaken at this time concerning routines in the home for healthcare appointments. While staff undertake actions to make follow up appointments, there is currently no system in place to remind or prompt staff when the appointment is due. This has resulted in a blood test being missed and then discovered at a later date. The manager and staff considered this and an appointments book was started before the completion of this inspection. Where creams are frequently used for service users healthcare and these are stored in rooms, a risk assessed must be completed and clearly identified on care plans. On a tour of the home, it was identified that a service user with complex needs did need immediate refurbishment in her room. The manager stated that routine cleaning was undertaken but this evidently not sufficient to maintain an acceptable standard. The manager actually contacted family members and senior personnel in the organisation and arranged for this to be dealt with. While ensuring a solution at this time, the manager and staff must take time to see where standards in the home need attention and not wait for these areas to be pointed out. A snag list for each room in the home or discussions at staff meetings can identify areas before they become too problematic. Individual care plans and pre admission assessments are in place but a sampling of files showed that these records are often muddled and information is not easily accessed. This does not ensure staff are providing care appropriately and may leave service users at risk. The care plans do have dividers but these are not labelled to give direction to a specific area of care. This means having to flick through the whole file for information that is often just placed into a file, not being affixed, and this again can easily be lost. Staff do support service users but this support must be fully documented to evidence staff routines Medication was found to be stored appropriately at this time but the lighting over the medicine dispensing area is very dull. This does not support appropriate dispensing and could easily lead to errors being made. The lighting must fully support safe practice and needs to be brighter. There is a procedure in place for the administration of medication dated 2003, but this does not directly reflect the current routines in the home. A general organisational overview has been put into place, but the procedure must be a Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 13 step by step account of how medication is to be administered to comply with the requirements set by the Royal Pharmaceutical Society. The manager stated this would be developed to fully support staff and the well being of service users. Kent House DS0000023456.V301239.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Choice and autonomy are supported and encouraged, ensuring individuals have control over their own routines and life. This supports a good quality of life and independence. All aspects of service user needs are met by the home and family, friends or advocates are encouraged to maintain contact. Service users stated they enjoy their food, a variety of meals are offered at all times and special choices, needs or diets are catered for. EVIDENCE: Discussions with service users and comments made on the questionnaires received at this time, all confirm that the wishes and needs of service users are, in the main, being met. Visitors were observed being welcomed into the home during this inspection and service users stated that family and friends are always welcomed. Visitors confirmed they are made welcome and can discuss any matters with the manager or staff available. This supports Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 15 independence, integration and ensures service users enjoy a good quality of life. The lunchtime meals looked and smelt appetising. Service users comments and questionnaires received all confirm the food is good and that alternative meals are always offered. The chef is aware of individual tastes and also cooks food to the liking of the service user. This confirms that staff are meeting individual needs and recognising individual preferences. Records are taken to identify any problems with eating and this also ensures the good health of the individual. A gold food award has been achieved by the home for 2006. Photographs are on display in the main hallway showing the D Day celebrations that were enjoyed in the home. One questionnaire received has described this as ‘a very enjoyable day’. Service users and staff dressed up for this occasion and photographs show a very successful day. Dial-a-Ride is used for outings to the shops and for trips out. A mobile library scheme is to be brought into the home to enable a good choice of reading for service users. There is a beauty salon in the home where service users can enjoy hairdresser, beautician and holistic massage. One person explained how this massage had helped with pain relief in the past. Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users and family members are confident their complaints will be listened to and acted on. Service users stated they feel safe and cared for in their home. There are no procedures for staff in the event of any abusive situations being suspected or reported. The current abuse policy is old and does not reflect current legislation. This is not ensuring the safety of service users or supporting staff to undertake appropriate action. There is no formal recording of complaints, investigation and outcomes. This is not supporting service users or ensuring appropriate procedures are being followed. EVIDENCE: Two responses to questionnaires stated there was not full awareness of the complaints procedures in the home or where to access an inspection report. The manager stated she would ensure people are made more aware of procedures and reports. However, a copy of the complaint policy is on display and is also contained in the Service User Guide that is in each service user room. Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 17 A formal complaints book must be in place to ensure full details of all complaints and subsequent action is fully recorded. Two complaints were Placed loosely in the folder and telephone conversations and discussions have not been recorded. An appropriate procedure must be developed to ensure legal requirements are met with fully supporting evidence. A full procedure is required to support dealing appropriately with any complaints received. This will ensure full and required documentation is on file and will also support staff in the absence of the manager. There is a very old policy on records regarding abuse. This is the same with almost all policies and there are no procedures in place to support staff. Policies on file have clearly been copied many times, some statements are ambiguous and open to personal interpretation. This is not supporting staff or service users or ensuring actions meet current legislation. This has been identified in previous inspections, but to date, appropriate procedures have not been developed. One document on abuse states that staff have to ‘decide if alleged abuser is to be suspended’ and there is no mention of involving other agencies such as Adult Protection or CSCI. At this time, 30 policies were sampled and of these, 4 were not dated, 14 were signed by a person who has not worked for the organisation for some time and these were dated 2003 and 1 was date 2002. Staff are not being supported by these out of date documents and service users are not being fully protected or supported. Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 18 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, 20, 23, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While decoration and some refurbishment has enhanced some areas in the home, there are additional areas still needing upgrading before the home reaches an acceptable standard throughout. EVIDENCE: The communal areas of the home were found clean an odour free. The dining room had flowers on the table and presented a comfortable area in which to eat, however, the lighting is very dim and does need adjusting. On a tour of the home, it was identified that a service user with complex needs did need flooring replaced. The condition of the carpet was not acceptable and when this was pointed out, the manager actually contacted the organisation and arranged for this to be dealt with. While ensuring a solution at this time, the manager and staff must take time to see where standards in the home need attention and not wait for these areas to be pointed out. A snag list for Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 19 each room in the home or discussions at staff meetings can identify areas before they become too problematic. All other rooms and bedding were found to be clean and orderly at this time. However, attention must be paid to items on top of wardrobes, posing a potential risk to service users. There was also a bench and armchair obstructing a fire exit and stairs to a fire escape. A ladder had been left against the wall close to a lift. The manager explained a maintenance man who no longer worked in the home had left these. However, staff must remain vigilant and observe where safety of service users and staff is being put at risk around the home. The radiators are not covered in the dining room and at least 9 service user rooms had uncovered radiators. This has been identified on previous occasions and was to be dealt with on a rolling programme. To date, this appears not to have been addressed and during winter months, will pose an unnecessary risk to service users. Bathroom and toilet areas still present a very dismal and dull environment for service users. These require updating and brightening to give a more homely and relaxing atmosphere and to bring these areas up to an acceptable standard. Some service users rooms have en suite facilities that contain half baths. These are not being used as the size is not practical and service users feel unsafe when considering this stepping into this small area. These would be more beneficial as shower units or turned into wet rooms. This would enable a person with any level of independence to use this area and provide a very useful personal space. There are clear signs for emergency and fire exits, fire extinguishers are appropriately placed, clearly signed and serviced. There were no COSHH items in evidence, and cupboards posing a risk were appropriately locked at this time. The doorbell is currently not heard throughout the home. Any visitors or healthcare professionals could be kept waiting for some considerable time and this was the case with one visitor during this inspection. Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A training matrix has been developed and training is ongoing, ensuring staff skills support service users, however, training on abuse is to be identified. Staff are caring and consider the dignity of service users, creating a relaxed and calm environment. EVIDENCE: Staffing at the time of this inspection consisted of the manager, one senior carer, three care assistants, one cook and one domestic. Discussions with service users and questionnaires received confirm people in the home feel happy and well cared for. Service users were seen to be comfortable while enjoying chatting with staff and the inspector. Staff demonstrated a good awareness of their roles and responsibilities, plus the needs of service users. Family members confirmed they are kept informed of any changes with regard to care and they are also comfortable discussing all matters with any member of staff. It was highlighted by staff and service users, that while needs are met in the home, additional staff would enable some discussions with service users to be undertaken. Service user questionnaires stated that staff are very caring and Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 21 work hard to make sure no one is kept waiting. They also observed that time is not spent sitting with service users to enjoy discussions in a relaxed way. One comment was ‘ an extra pair of hands would let staff relax with service users a bit more’. A sampling of staff files evidenced that recruitment procedures are appropriate and ensure the safety of service users. Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 22 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, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current acting manager is a suitable person and service users spoken to at his time confirmed they feel the home is well managed. While there are areas of the home that do require attention and action, the manager and staff group do, in the main, consider the health and welfare of service users. EVIDENCE: The manager works with an open door policy and is readily available for discussions to be undertaken. Service users spoken to at this time, both individually and in groups, confirmed they feel they are supported, can discuss matters with staff or the manager and feel they will be listened to. Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 23 Staff stated they feel supported by the manager and are able to discuss all issues that may arise. The staff team also support each other and it is felt that as a team, staff do work well. Consideration was being given at this time to one service user who was recently bereaved. Staff were being supportive and considering the well being of this person. Time was also being given to adjust to this situation and staff were clearly confirming with the person concerned, that there was no reason to rush into decisions. Dignity and privacy was also being supported at all times. While there are clearly areas in the body of this report that need attention and require staff to be more observant about safety elements around the home, staff do try to ensure the safety of service users. This was supported by observations at this time and thorugh discussions undertaken with service users who do feel safe in the home. Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 17 X 18 2 2 2 X X 2 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 2 Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 1 OP7 14 Care plans are to be in a format that support staff and ensure the full needs of service users are met. This brought forward from the last inspection report 31/10/06 2 OP8 12, 13 Risk assessments to be completed for any creams in service user rooms and these should easily be identified on care plans. 30/09/06 3 OP9 12, 13, 17 That a medication procedure is developed in line with the requirements set by The Royal Pharmaceutical Society. A copy of this procedure to be with CSCI by the stated date. 31/10/06 4 OP16 12, 13,17 A formal complaints book must be in place and records fully evidence all investigations and actions taken following a complaint. 31/10/06 Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 26 5 OP18 12, 13,17 That a complaints procedure is developed to support staff and service users. The abuse policy must contain up to date, clear and full information that supports staff and protects service users. This brought forward from the last inspection report 31/10/06 6 OP18 12, 13,17 31/10/06 7 OP19 16 & 23 Environmental improvements are required to continue to provide suitable and comfortable surroundings for service users. Particularly in toilet and bathroom areas. Plan of action to be with CSCI by the date stated. 31/10/06 8 OP18 12 & 17 Local procedures are to be developed to support staff in their duties, to support the induction process and to protect/support service users. This brought forward from the last inspection report. Plan of action to be with CSCI by the stated date 31/10/06 9 OP24 12, 13, 23 All service user rooms must be made safe and items on top of wardrobes removed. 30/09/06 10 OP25 12, 13, 23 Fire escapes are to be unobstructed at all times in compliance with fire safety regulations. 12, 13, 23 Radiators must be covered for the safety and well being of service users. Plan of action to be with CSCI by 30/09/06 11 OP25 OP38 30/09/06 Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 27 the stated date 12 OP25 OP38 12, 13, 23 Risk assessments to be undertaken to ensure complete safety of service users in all areas where radiators are uncovered. 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Kent House DS0000023456.V301239.R01.S.doc Version 5.2 Page 29 - 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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