CARE HOMES FOR OLDER PEOPLE
Kenyon Lodge 99 Manchester Road West Little Hulton Manchester M38 9DX Lead Inspector
Liz Holt Unannounced Inspection 25th May 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kenyon Lodge DS0000006713.V335600.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.V335600.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 Trees Park (Kenyon) Ltd Ms Carol Lambert Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (58), Physical disability (2) of places Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The home accommodates a maximum of 60 service users requiring either nursing care or personal care only. Two named service users who are out of category by reason of age may be accommodated. Should either of these service users no longer require their places at the home, or reach the relevant age, the category will revert to old age (OP). 15th June 2006 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 personal care only and 30 people who require nursing care. All personal 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.V335600.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 Friday 25th May 2007 from 11.15 until 16.00 hours. A further visit to continue the inspection process was made on Saturday 26th May 2007 from 11.45 until 15.30 hours. During these site visits time was spent talking to some of the people who were living there, visitors/relatives, some of the staff, the manager about day-to-day life in the home and to establish what the home was like for residents living there. A partial tour of the premises was undertaken and a review of documents and care files. Information was gathered as part of the inspection process, which included a Self Assessment Quality Assurance questionnaire, which was well completed by the registered manager. The questionnaire gave information about the residents, the staff and the building. Two resident/relatives questionnaires were returned to the Commission. Since the last inspection the Commission has received no complaints/concerns. One complaint has been made directly to the home, which has been appropriately investigated. What the service does well:
The home ensures that prospective people are assessed properly before an offer of a place is confirmed and have written information about the home. Staff were seen talking and generally having positive relationships with the people living at the home. It appeared that the privacy and dignity of the people was protected. Relatives and some of the people who could express a view said, “the staff are very kind hearted and gentle”. The home had an open visiting policy and relatives spoken to said they were made to feel welcome whenever they visited. One person’s daughter said, “It doesn’t matter whether it is me, my brother’s or the dog, visiting Mum, we are all made welcome here”. A choice of food is available at each meal and the people living there would be provided with what is on the menu. The residents’ spoken to were happy about the choice and quantity of food. The procedures in relation to the administration and recording of medication were satisfactory at the time of this visit. Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 6 The procedure for people living at the home and/or their representatives to raise any concerns or complaints was displayed in the entrance hall and was easy to follow. The people living at Kenyon Lodge benefited from the commitment and leadership of the manager. What has improved since the last inspection? What they could do better:
Some shortfalls in the recording of appropriate information in the care plans may put people at risk of not having their needs fully met. Information gathered during the assessment phase should be used as part of the care planning process to ensure people’s health, personal and social care needs are met. Individual care plans should be made for each need identified. Risk assessments should be fully completed. Particularly in relation to the nutritional needs of the people accommodated. The systems in place for recording the care of people requiring regular care and attention must be improved. Although changes had been made to the
Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 7 type of charts used, the shortfalls in filling these in may lead to peoples needs not being fully met. An audit should be carried out to ensure the equipment provided is appropriate to meet the needs of the people accommodated. The appropriate beds should be provided to meet the needs of the people accommodated including any bed rails attached to these beds. A number of people living at the home were seen to have unclean and lengthy fingernails. Nail care kits were readily available however staff must include nail care and review this as part of the daily care provided to the people who need assistance. The manager had recently appointed a new activities organiser who had not yet started in post. A discussion with the manager highlighted plans to be able to provide more appropriate and suitable activities in the home according to the wishes of the people living there. Although the home has a programme of redecoration in place this appears to be slow. Following a requirement to replace bedding and soft furnishings at the last inspection some further curtains, duvets should be replaced and floor coverings should be kept clean. Although the home did not have any staff vacancies at the time of this visit, the manager must review the skill mix and number of staff provided to ensure the needs of the people living at the home are fully met. Consideration should be given to providing staff with training specific to meeting the needs of a person with a dementia type illness. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kenyon Lodge DS0000006713.V335600.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.V335600.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people and their representatives have the information needed to choose a home, which will meet their needs. They can be confident they will have their needs properly assessed as part of the admissions procedure. EVIDENCE: The manager had developed a new brochure about the home to inform prospective people about Kenyon Lodge. A Statement of Purpose and a Service User Guide was available in each person’s bedroom. One person’s relative spoken to said she had visited the home and a number of other homes prior to finding Kenyon Lodge for her mother. She felt she was made welcome when she visited and had been given an opportunity to talk about her mother’s care needs. Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 10 Another relative said he visited the home 6 times at different times of the day to assess whether the home was suitable for his mother. He said at each visit the staff were “welcoming”. “I feel the majority of staff want to do the utmost care”. When Mum was admitted they talked through her care plan in detail, they have not really done it since however they are always updating me and letting me know how she is. One person who was recently admitted to the home said she felt the home was meeting her needs and she was settling in quite well. A discussion with the manager highlighted that people were welcome to have a meal pre admission and could spend time in the home to try and get a feel for it. The admissions procedure was discussed with a staff member who said she considered it important to make a person feel welcome when they were admitted. She could talk confidently about the admissions procedure. Three assessments of need, which included all the activities of daily living, were reviewed. Two of these were clearly detailed and completed by the manager or senior nurse and the information was used to form the care plan. The information was put on a pre printed assessment form, however for one person this was not adequately transferred into the person’s care plan in relation to her specific likes for personal care. The home did not provide intermediate care. Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls in the recording of the health and personal care, which a person receives in the home, may lead to their needs not being fully met. EVIDENCE: Five care plans were sampled. A requirement made at the last inspection was in relation to fully identifying the person’s needs and reviewing this plan when a person’s needs change. Daily entries in the care plans should be clear and consistent. It was clear that the staff had made considerable improvements in the recording of the care plans and the system in place was user friendly. Staff spoken to with responsibility for writing the care plans did find it difficult keeping these up to date, accurate and detailed within the span of duty on each shift for the number of people accommodated. (See staffing). Some of the people spoken to felt the staff were often “too busy to have the chance to just “sit and chat to us”.
Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 12 At the time of this visit six people were cared for in bed due to their complex health care needs and poor health status. The pressure relief charts and the dietary intake charts for some of these people had not been well recorded and the staff were not seen to check on these people as a matter of routine over a period of time. It was of concern that these people’s needs were not being fully met. People who could express a view were positive generally about the care they received. One person who had a fractured arm following a recent fall, stated she was “well cared for and the staff were gentle and kind to her”. One gentleman did comment that he waited a long time for his request for attention to be acknowledged by the staff sometimes. During this visit the call bell sometimes went off for a lengthy period of time before it was answered. The manager chased this up more than once. This practice is poor as people living at the home may have to wait too long to have their needs met. One care plan reviewed showed the person’s identified needs in the assessment had not been followed through to the care plan. District nurse involvement had highlighted the need for a prescribed cream. Staff were not aware of the cream and this had not been carried over to a new medication administration chart. A review of the daily statements showed no further comments in the daily statements re the person’s identified needs and there was no specific care plan for this need. When the person in charge was questioned regarding the current status of this person, the carer said the night staff had assisted this person with personal care and therefore she could not comment, however this person was responsible for writing the daily report. Care plans reviewed in relation to wound care showed these to be clearly recorded updated and evaluated regularly. Other daily statements made on the whole were detailed and had improved following the last inspection. It is recommended these comments reflect on the specific care plans created. For one person it was pleasing to see that following an assessment of need, the care plan stated this individual required 2 hourly positional changes. It was good practice to see the following; a sore area had been highlighted, a specific care plan had been written and an evaluation after a short timescale had been carried out. Risk assessments concerning all aspects of risk to each individual, including the risks of falls had been completed. Improvements were seen in the care plans of the need to refer a person to the dietician and staff had undertaken some training in the use of the nutritional tool, however not all risk assessments were completed fully. This shortfall in the assessments may lead to people’s dietary needs not being met in full. Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 13 Not all the beds were appropriate to meet the nursing needs of the people living at the home. The beds should be appropriate to meet the needs of the people accommodated to ensure the safety of the staff and the person accommodated. At time of inspection it was good practice to see the manager was doing an audit of a sample of care plans and highlighting areas of weakness for the staff to address. The night reports regularly stated, “good night, slept well”. This needs to be reviewed to show any care provided during the night for the people accommodated. People who could express a view said they were treated with respect and their privacy and dignity needs were met. Some of the staff were seen to be very kind and sensitive when they were talking or explaining something to a person in the home. A number of people’s fingernails were seen to be lengthy and unclean. It was pleasing to see that nail care kits were readily available and staff was seen making an effort to assist some of the people when this was raised. The staff on a regular basis should monitor this. From a sample of charts reviewed, the recordings on the medication administration records were generally satisfactory. Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social, cultural and recreational activities generally meet the expectations of the people living at the home. EVIDENCE: Relatives and friends are able to visit the home at any time during the day and a policy was available regarding open visiting. For nighttime visiting relatives are requested to inform the home for security reasons. Several relatives/friends were seen visiting people at the home during the site visits. Staff were seen to have a good relationship with visitors present during the two visits. People accommodated at the home said their relatives and friends were made to feel welcome and were encouraged to visit the home and take their relative out on excursions. The people living at the home could see their relatives in the communal lounges or in the privacy of their own bedroom. A discussion was held with the cook who clearly enjoyed her role and knew the individual preferences of the people who came to eat in the dining room.
Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 15 Choices were offered at each meal and care staff were seen asking people who could express a view what food they wanted for their evening meal. Meals are served at certain times in the communal dining rooms. The food looked generally wholesome and appealing. Four people spoken to said they liked the meals provided at the home. A number of people required assistance at mealtime. It was poor practice to see that the nurse in charge was called away for a review meeting during the mealtime when she was assisting a person with their meal. The nurse in charge returned to the dining room, however this shows a shortfall in the management of the nurse’s time who was doing her best to deal with both situations. Staff were on the whole supportive of the people who required assistance during mealtime and attempts were made to make this a pleasant sociable occasion. The activity co-ordinator had recently ceased employment at the home, however it was pleasing to note that a new person was due to start at the end of May. It was evident that some staff did try and provide a stimulating environment for the people living there by listening to music, encouraging singing, and reading newspapers or magazines with some of the people. One person said he had recently enjoyed a social event where he could dance in the home. A formal schedule of activities was not available at this visit, however a discussion with the manager showed some of her ideas for the near future when the new activities person is in post. Two of the people living at the home had said they liked gardening and it was clear staff had made an effort to encourage them to assist in the potting of some plants to enjoy on the patio area outside. A recent letter of thanks to the staff at the home said, “ We would like you to know how much we have appreciated the care Mum has received in the last few years. She referred to Kenyon Lodge as home. We were always made to feel welcome. The warmth and sensitivity given to us was such a help.” Kenyon Lodge DS0000006713.V335600.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were able to raise any concerns by following a clear and readily available complaints procedure and are protected from abuse. EVIDENCE: The complaints procedure was available on display and information on how to make a complaint was included in the Service User Guide to the home. All staff have received training in Safeguarding Adult procedures and when questioned staff aware of the course of action to take in the event of an allegation of abuse. People who responded to the service user survey said that they knew how to make a complaint. Since the last inspection the Commission has received no complaints/concerns. One complaint had been made directly to the home, which had been appropriately investigated. A number of cards and letters were seen from relatives of people who had lived at Kenyon lodge complimenting the home on the care and the support the staff had provided. Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some shortfalls in the environment made the home look tired and unclean. EVIDENCE: The home generally provides a homely environment for the people living there however some delays in the redecoration programme have left some bedrooms still in need of painting and the soft furnishings replacing. Some bedrooms had been repainted since the last inspection and the delays in this programme were said to be due to the need to vacate a bedroom for this redecoration to happen. A partial tour of the premises was made. This included the communal areas, toilets, and a number of bedrooms. There was wheelchair damage noted to a number of the doors, which makes the paintwork look shabby. A requirement made at the last inspection included the need to provide adequate bedding and
Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 18 soft furnishings. This has been addressed in part however curtains in some of the bedrooms and duvet covers looked tired and should be replaced. Three bedroom carpets had been replaced this year however a number were seen to need a thorough cleaning or replacing. At the time of this visit the carpet cleaner was out of order and as a matter of urgency this required repairing. A cleaning programme was in place and two new housekeeping staff had recently been appointed. A pleasant garden/patio area with an awning was accessible to the people living at the home and two people said they had been enjoying time they spent in the garden. Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls in the staffing arrangements may lead to people’s needs not being fully met. The procedures for recruiting staff were robust and provided adequate safeguards to protect people living at the home. EVIDENCE: At the time of the site visit the home provided care and accommodation for 26 people requiring nursing care, and 29 people in receipt of personal care only plus 3 people in hospital. Agency staff are used to address shortfalls in the staffing levels however the 2 vacancies for care staff had just been filled and recruitment information was being gathered. On the day of the visit 3 care staff on the nursing floor were temporary staff however 2 of these had worked at the home before. One Registered Nurse was responsible for overseeing the care of the 29 people who required nursing care. On the personal care only floor the senior carer was carrying out writing tasks for a lengthy period of time whilst the care and supervision of the people living there was left to two recently recruited staff and an agency care worker. A discussion with the manager and the staff highlighted the need to review the skill mix, the number of staff and how they are deployed to ensure the needs of the people living at the home are fully met.
Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 20 From observations made of some of the staff’s interactions with some of the people accommodated, consideration should be given to specific training to meet the needs of the people accommodated with a dementia type illness. Three care staff spoken to were new to the home and were finding the basic induction programme a good starting point. A sample of registered nurses and care staff files were examined. The files examined contained the appropriate information and checks to ensure the staff are safe to work with the people accommodated including POVA and CRB checks. Following a good practice recommendation made at the last inspection it was pleasing to see that a recruitment checklist had been developed. A requirement made at the last inspection was met with further training provided. The home employs 24 permanent care staff with 12 of these having successfully achieved NVQ level 2. A further 5 care staff were working towards NVQ level 2. Staff spoken to were positive about the training they had done and were enthusiastic to do more. Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements had continued to have been made in management practices since the last inspection, however some practices in the home did not promote and safeguard the health, safety and welfare of the people accommodated. EVIDENCE: The people accommodated benefit from a committed and experienced manager who is a qualified nurse. She has undertaken a range of training and is currently studying for the Registered Managers Award. The manager clearly takes her responsibilities seriously and is keen to review and improve the service provided. Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 22 One relative said; “the matron keeps everyone on their toes in a polite but firm way and has been very helpful and quick to respond to any queries.” The previous report highlighted the need to review the quality monitoring system the manager was using. Questionnaires had been developed however a quality survey had not been carried out. A requirement was made for the survey to be sent out to people living at the home, their representatives and visiting professionals. An action plan can then be developed from these responses to address any issues raised in the report. The manager had the policies and procedures in place to ensure the financial interests of the people living at the home are safeguarded, however individual records were not looked at during this visit. The pre inspection questionnaire completed by the manager prior to this inspection showed that policies, procedures and risk assessments were in place in relation to health and safety issues. The manager has an open style of communication and encouraged families and friends to express any concerns or issues that need addressing. One relative “popped” in to see the manager during the site visit and was very positive about the care her mother received. Families were involved in updates of care planning and meetings were arranged to discuss any issues. The fire logs were seen and the required checks had been made. Following a requirement at the last inspection, the thermostatic mixer valves had been adjusted and /or replaced as necessary. The emission of the hot water was now safe in all rooms and regular maintenance checks were being carried out. Staff need to record the temperature of the water before a person has a full body immersion in a bath. Any reported accidents/incidents were recorded in an appropriate log book. The manager had an accident report log which showed the monitoring of accidents in the home. Kenyon Lodge DS0000006713.V335600.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 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 OP7 Regulation 13 Requirement The assessed and changing needs of the people accommodated must be reflected in the care plans so that staff are aware of changes and the actions to take to meet those needs. The daily entries must be clear and detailed. This remains outstanding from the 01/08/06. The nutritional risk assessments must be clearly recorded to ensure people receive support with their diet as needed. Food and fluid records and pressure relief charts must be clearly recorded to ensure people’s needs are met. This remains outstanding from the 31/07/06. A programme of renewal must be kept to so that peoples bedrooms and communal areas are furnished and well equipped. This must include carpets, bedding, and curtains.
DS0000006713.V335600.R01.S.doc Timescale for action 25/07/07 2. OP8 15 13/07/07 3. OP19 24 31/07/07 Kenyon Lodge Version 5.2 Page 25 4. OP24 16 5. OP27 18 6. OP33 24 The responsible person must ensure that appropriate adjustable beds are provided for people receiving nursing care and appropriate bed rails are fitted. The numbers and the skill mix of the staff on duty must be reviewed to make sure that the people accommodated receive the appropriate care to meet their needs. Specifically, the number of nurses must be increased and senior staff on the personal care only floor must be properly deployed. The responsible person must ensure that an annual development plan based on seeking the views of service users are in place to measure success in meeting the aims, objectives and statement of purpose of the home. 09/06/07 13/07/07 30/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP30 Good Practice Recommendations It is recommended that staff receive training in the care of older people with a dementia type illness to assist in their communication and care of some of the people living in the home. It is strongly recommended that staff ensure the fingernails of the people living at the home are kept clean and at a comfortable length. 2. OP8 Kenyon Lodge DS0000006713.V335600.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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