Inspection on 15/06/06 for Kenyon Lodge

This inspection was carried out on 15th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Kenyon Lodge 18/08/09

Kenyon Lodge 25/02/09

Kenyon Lodge 16/05/08

Kenyon Lodge 25/05/07

Kenyon Lodge 02/03/06

Kenyon Lodge 04/12/04

Kenyon Lodge 28/06/04

Kenyon Lodge 31/01/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Kenyon Lodge 99 Manchester Road West Little Hulton Manchester M38 9DX Lead Inspector Elizabeth Holt Key Unannounced Inspection 15th June 2006 09:00 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 Kenyon Lodge DS0000006713.V301255.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. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kenyon Lodge Address 99 Manchester Road West Little Hulton Manchester M38 9DX 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) 0161 790 4448 Mr Prabhdyal Singh Sodhi Ms Carol Lambert Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (59), Physical disability (1) of places Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home accommodates a maximum of 60 service users requiring either nursing care or personal care only. Minimum staffing levels as specified in the Notice issued by the previous regulating authority on 2nd December 1994 shall be maintained. Staffing levels in accordance with the Residential Forum Guidance for Staffing in Care Homes for Older People shall be maintained for those service users requiring personal care only. One named service user who is out of category by reason of age may be accommodated. Should this service user no longer require their place at the home, or reach the relevant age, the category will revert to old age (OP). The service should at all times employ a suitable and qualified experienced manager who is registered with the Commission for Social Care Inspection. 2nd March 2006 5. Date of last inspection Brief Description of the Service: Kenyon Lodge is a registered care home providing nursing care and personal care and accommodation for up to 60 older people. Care is provided to 30 residents assessed as needing residential care and 30 residents who require nursing care. All residential care beds are located on the first floor. The home is set in its own grounds with a designated parking area and a large secure garden area to the rear with patio area. The home is situated on a main route in Little Hulton enabling easy access to Manchester, Salford and Bolton. The current scale of charges at the home is £355.52 -£525.00 per week. Costs in addition to the fee are hairdressing £3.50-£16.00, Chiropodist £10.00 per visit, newspapers-varied and toiletries which are charged on an individual needs basis. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on the 15th June 2006 and a further visit to meet with the manager on the 20th June 2006. All of the core National Minimum Standards (NMS) were reviewed during this inspection. Information was gathered as part of the inspection process, which included a questionnaire completed by the manager, which gave information about the residents, the staff and the building. Information held by the Commission, for example, notifications of significant incidents were also reviewed. Time was spent talking to the residents and visiting relatives, the manager and the staff team about the day-to-day life in the home and to establish what the home was like for the residents living there. A partial tour of the premises was undertaken and examination of documents and care files for individual residents. Ten resident/relatives questionnaires were left to be forwarded to the Commission. Three responses were received at the time of this report being written. The Commission for Social Care Inspection have investigated one complaint under the Adult Protection procedures since the last inspection. Following the findings in this investigation a requirement was made in relation to the home reviewing their procedures in the event of an acute episode for a resident and in the recording of information in the care plan. Positive feedback however was given to the home in relation to the care provided for the resident during their stay at the home and this included compliments from other visiting professionals. The majority of the areas identified in the last inspection on the 2nd March 2006 had been met. The Commission for Social Care Inspection had received a pre-inspection questionnaire before this inspection. The previous report should be read together with this one to get a better picture of the care being provided at the home, as the Commission for Social Care Inspection only looked at the key standards during this inspection visit. What the service does well: Residents said the staff were generally kind and friendly. A relative commented, “the staff are generally very kind and understanding”. The level of cleanliness throughout the home was satisfactory. Residents said the home was comfortable and homely and they were able to bring in their own pieces of furniture into their room. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 6 The home has an open visiting policy and residents said that their visitors were always made to feel welcome. A choice of food was available at each meal and residents would be provided with an alternative if they did not like what was on the menu. Residents spoken to were satisfied with the food provided. Care staff were seen helping the residents who required assistance at mealtimes in an appropriate way. The medication procedures examined were adequate at the time of this inspection. The relationships between the residents and the staff were generally satisfactory. Staff were seen talking and joking in a respectful way with the residents. The complaints policy and procedure was displayed and easy to follow. What has improved since the last inspection? What they could do better: The process followed when a new resident is admitted to Kenyon Lodge should be improved to consider more fully the individual needs, concerns and anxieties of the prospective resident and their families. Although some improvements were seen in the care plans since the last inspection, a number of shortfalls were noted in the documentation on the nursing floor. These shortfalls in the appropriate recording of information have the potential to put residents at risk. Information about the residents social care needs was minimal however the staff were making attempts to involve family members to assist in providing this information. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 7 At the time of this inspection 6 of care staff only had successfully completed their National Vocational Qualification level 2. The manager was encouraging the staff to undertake this course. Following this inspection an immediate requirement was made for staff to receive updated Moving and Handling training, following observation of poor practice during this inspection. Other training needs identified including wound care and for Adult protection training to be actioned. 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. Kenyon Lodge DS0000006713.V301255.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 Kenyon Lodge DS0000006713.V301255.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): 3 and 6 Quality in this area outcome is adequate. This judgement has been made using evidence made available and following a visit to the home. Procedures are available to ensure the needs of prospective residents are fully assessed before they are admitted to the home. The procedures were not always followed which could lead to residents needs not being met. EVIDENCE: The files of three residents who were recently admitted to the home were examined. The manager had visited two of the three residents to ensure the home could meet their individual needs. A pre assessment form was used to record the assessment carried out on a prospective resident. The information on this form was not fully completed and one of the residents was not confident that the home could meet her individual needs. For residents who are referred through Care Management arrangements the home obtains a summary of the Care Management assessment prior to admission. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 10 Discussions with two of the new residents and/or their representatives highlighted that the admission process had not addressed a number of concerns for these residents and their representatives. Residents were provided with a statement of terms and conditions when they were admitted to the home. It was pleasing to see that the relatives of the prospective residents had visited the home prior to admission. The home does not provide an intermediate care service. Kenyon Lodge DS0000006713.V301255.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 and 10 Quality in this area outcome is adequate. This judgement has been made using available evidence including a visit to the home. Each resident had an individual plan of care, however some areas of the care plans required improvements to ensure the residents’ health, personal and social care needs are fully met. The staff treated the residents with respect and their privacy was upheld. The medication procedures were adequate to protect residents. EVIDENCE: The home had worked hard on the personal care only floor to improve the care plans, however there were a number of shortfalls noted on the nursing floor where sufficient and accurate detail was lacking. The manager had held meetings with the staff to inform them of the detail required in the documentation. Staff felt this had improved the documentation and the level of communication between staff. The evaluations in these documents were detailed. One area for development was in relation to the social care plan assessments. The person in charge stated that they were in the process of encouraging family members to complete them. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 12 Requirements made at the previous inspection in relation to care plans and risk assessments had not been fully addressed. The nurse in charge (bank staff) on the day of the inspection was not fully aware of the existing wounds when questioned. A discussion with the nurse highlighted a training need in relation to wound care and a requirement was made. Whilst there were some examples of good practice seen, some of the care plans examined in relation to wound care had not been updated or evaluated as required. There was evidence of involvement with the Tissue Viability Nurse specialist as required. Sometimes the care required was not followed up. The care plan stated that a resident who had lost weight required weighing weekly to monitor this, however there was no record to show this had been done. Evidence was lacking of resident/relatives involvement with the care plans. One relative commented that no one had discussed her mother’s needs with her. As raised at the previous inspection dietary and fluid balance charts were poorly recorded. By 2.00pm one resident had only 250mls of fluid recorded as taken since 8.00am. Staff must record if they have offered fluids and a resident has refused this. During the course of the inspection the staff were heard talking to residents with respect and their need for privacy was respected. Staff were seen to be kind and sensitive in their approach. Following the Adult Protection investigation a requirement was made in relation to the appropriate detail to be recorded in the daily statement. This was following an acute episode for a resident and the information provided lacked some detail and was recorded by a care worker. Medication records were examined and the recordings were generally satisfactory with codes used appropriately. One example of poor practice was in relation to not recording the detail on the reverse of the medication chart if a particular drug was not administered. There was an up to date list of staff signatures that were responsible for administering medication. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 13 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 and 15 Quality in this area outcome is good. This judgement has been made using available evidence including a visit to this service. Activities were provided and residents were encouraged to maintain contact with family and friends. Residents could exercise some choice over their lives and the residents received a balanced and nutritious diet. EVIDENCE: The home had an open visiting policy and residents commented that their visitors were made to feel welcome in the home. The visitors’ book confirmed there were regular visitors to the home. The staff was seen to have a good rapport with the visitors present during the inspection. The activity co-ordinator was employed for 28 hours per week. Staff commented she did consult the residents on the activities they wished to undertake however during the inspection there was no evidence to suggest any activities were carried out. Some residents and staff commented that at times they felt residents would benefit from some further activities/stimulation, which was difficult for them to provide due to meeting the personal care needs of the residents. When possible one staff member said he talked through the newspaper headlines and chatted about current affairs. A recommendation was made that this is reviewed. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 14 Residents said they had enjoyed recent trips out including a trip to Blackpool and Wigan Pier. One resident confirmed that she received Holy Communion in line with her wishes on a regular basis. Evidence was seen that residents are able to bring personal possessions into the home. A discussion with one resident highlighted that an appropriate risk assessment was needed for her to have a kettle in her bedroom. She wanted this level of independence and found some of the staff respected her wishes for a cup of tea when requested however at other times the staff were “obviously too busy or forget.” The menus were varied and offered a varied, wholesome and nutritious diet. One resident commented that she was unable to see the menu board and was not offered a choice of meal pre mealtimes. Residents who could express a view said the food was good and there was always enough food to go round. The chef stated that if residents did not like the meal she would prepare something else of their choice. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12-month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this area outcome is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefited from having a policy and procedure for managing complaints. However, staff not having training in implementing the adult protection procedure has the potential to put residents at risk. EVIDENCE: The complaints procedure was available on display. The home held a record of any complaints/concerns raised. Four complaints made to the Commission for Social care Inspection over the last 12 months have been dealt with according to the home’s complaints procedure. One of these was upheld and one was partially upheld. Residents and relatives spoken to said they knew how to make a complaint and felt confident a complaint would be dealt with appropriately. A number of staff had received training in Adult Protection procedures and were aware, when questioned, about the course of action to follow in the event of an allegation of abuse. A number of staff had not received training in Adult Protection and a requirement was made. This training should be extended to all staff working at the home. An investigation into a complaint under Adult Protection procedures concluded that there was some poor practice in the time delay of the staff seeking the appropriate medical support for the resident and in the record keeping of the Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 16 chronology of events leading to the residents’ admission to hospital. (See standards 7-11). A requirement was made accordingly. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12-month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 22 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was generally clean, comfortable and homely. Some areas required attention as they put the residents’ safety at risk. EVIDENCE: The home provides a clean and homely environment. The garden area was accessible to residents in wheelchairs which some commented they had been enjoying in the warm weather. A partial tour of the premises was made. This included seeing communal areas, toilets and a number of residents’ bedrooms. Some of the duvet covers, and soft furnishings showed signs of wear and tear. Replacement of these must be made to maintain the homely environment. Residents said the home was comfortable and homely and that they were able to have some of their own furniture in their room. Décor and furnishings were acceptable generally and there was a programme of redecoration in place. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 18 The following required attention; toilet light on the first floor, no liquid soap in the soap dispensers on the first floor bathroom and toilet, shower room on the first floor could benefit from being screened off to make this room feel homely. During the visit it was noted that a large number of the wheelchairs had their footplates missing. It was pleasing to see that on the second visit to the home on the 20.06.06 the maintenance man had reviewed all the wheelchairs to ensure the footplates were in place. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. The numbers and skill mix of staff meets Service users’ needs. 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 and 30 Quality in this area outcome is adequate. This judgement has been made using available evidence including a visit to this service. The deployment of the staff available was not always sufficient to meet the residents’ needs. The home could not demonstrate that its staff had completed the required training to meet the resident’ assessed needs. Recruitment and selection procedures were adequate to protect residents. EVIDENCE: At the time of the inspection the home accommodated 22 residents in receipt of nursing care and 17 residents in receipt of personal care only. On the day of the inspection the nurse in charge was a temporary staff member whose knowledge of the individual residents was poor. Staffing levels after lunch were poor, all the residents were left unsupervised in the main lounge, however one resident was being sent to hospital during this time. A resident was slipping down her chair and required assistance. Once alerted to the situation, the staff proceeded to use an out dated moving and handling technique. The resident acknowledged how uncomfortable this was. A letter of immediate requirement was made for all staff to receive up to date moving and handling training. One care worker was observed to tip a wheelchair backwards when she was assisting the resident to leave the dining room. It was pleasing to see that another care worker intervened to put the footplates in place and alert the carer to the appropriate practice. Staff must be monitored and supervised to ensure they carry this out following the training. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 20 A sample of registered nurses and care staff files were examined. Policies and procedures were available to ensure the right procedures are carried out when staff are recruited to the home. The files examined contained the appropriate information to be held by the home including POVA and CRB checks. It is recommended that a recruitment checklist be completed to ensure the files contain the necessary information and that staff currently employed by the home are not used as referees for potential new recruits. The home employs 22 care staff, from information provided by the home, only 6 of carers hold the National Vocational Qualification level 2. The manager was encouraging the staff to carry out this training and a requirement was made to address this. A training matrix was available however staff should have an individual training and development plan. Staff spoken to said they did enjoy the training days and found them useful. A structured induction programme was available and two staff commented they had followed this programme. A discussion with the manager highlighted the need for other staff to be involved in this process too and for the individual themselves to comment on how they have achieved their outcomes. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The quality in this area outcome is adequate. This judgement has been made using available evidence including a visit to this service. The manager had improved some of the management practices in the home including staff supervision and induction. A system is in place to monitor the service however this requires reviewing. Not all areas of the home were seen to promote the safety of the residents and staff. EVIDENCE: It was pleasing to see that following a requirement made at the last inspection notifications of accidents were received by The Commission for Social Care Inspection. The manager carried out an audit of accidents occurring in the home and amended risk assessments as necessary. A questionnaire was available to seek the views of residents/relatives however there was no evidence to suggest this had been sent out. In order for the Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 22 residents/relatives to have a say in the running of the home it is required this form is reviewed and that a quality audit is sent out to visiting professionals. The administrator has lead responsibility for managing residents’ personal allowances. Secure facilities were available and the management of these allowances was satisfactory. Following a review of the water temperature checks it was evident that the boiler temperatures were too high. An immediate requirement was made for the thermostatic mixer valves to be replaced/adjusted as necessary to ensure the safe emission of water in all rooms. Staff must record the temperature of the water before a resident uses this equipment. Maintenance records showed the home had used the services of Gas Force to assist them in maintaining the mixer valves, however the Commission requires confirmation that the water temperatures are satisfactory and the appropriate work has been carried out. Fire safety checks were being carried out on a regular basis and a fire alarm test was carried out during the inspection. The pre-inspection questionnaire showed that health and safety checks were being carried out. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 3 X 2 X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14 Requirement Pre admission assessments must be undertaken and the outcomes of these must be clearly recorded to ensure that the service is able to meet the needs of the prospective resident. Care plans must fully identify the needs of the residents accommodated and must be reviewed when residents’ needs change. Daily entries must be clear and consistent. Nutritional assessments must be clear and staff must action the strategies where any concerns /risk exist about a resident’s weight. Fluid and dietary records must be accurately recorded. All staff must have training/guidance in the implementation of the Protection of Adults from Abuse. Adequate bedding and furnishings must be provided for residents in their own bedrooms. Timescale for action 01/08/06 2. OP7 13 31/07/06 3. OP8 15 31/07/06 4. OP18 13 04/08/06 5. OP24 16 30/08/06 Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 25 6. OP27 18 7. OP28 18 8 OP30 18 9 OP38 13 The staffing levels must be reviewed to ensure they are appropriate to meet the needs of the residents accommodated. The nurse in charge of the care home must be competent and experienced for the health and welfare of the service users. Evidence must be provided that all staff have undertaken the necessary training to ensure that it provides suitably qualified, competent and experienced staff to ensure the health and welfare needs of the residents are met. The boiler/thermostatic mixer valves must be replaced/adjusted to ensure the safe emission of water in all rooms. 31/07/06 17/07/06 14/08/06 24/07/06 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. 2. 3. 4. 5. Refer to Standard OP12 OP13 OP29 OP29 OP38 Good Practice Recommendations It is recommended that the care plans include a detailed social assessment of resident’s needs. It is recommended that the reason for not administering medication is recorded on the reverse of the medication administration chart. It is recommended that character references are sought from staff not employed at the home. It is recommended that each member of staff have a training and development plan. It is recommended that the quality audit form is reviewed and implemented. Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ 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 Kenyon Lodge DS0000006713.V301255.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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