Inspection on 01/11/06 for Kestrel Grove Nursing Home

This inspection was carried out on 1st November 2006.

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

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

Other inspections for this house

Kestrel Grove Nursing Home 27/02/06

Kestrel Grove Nursing Home 05/07/05

Kestrel Grove Nursing Home 24/01/05

Kestrel Grove Nursing Home 05/04/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Kestrel Grove Nursing Home Hive Road Bushey Heath Herts WD2 1JQ Lead Inspector Judith Brindle Key Unannounced Inspection 09:10 1 and 16th November 2006 st 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 Kestrel Grove Nursing Home DS0000022930.V317978.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. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kestrel Grove Nursing Home Address Hive Road Bushey Heath Herts WD2 1JQ 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) 020 8950 4329 020 8950 8074 Mr Paul Martin Tripp Mrs Kathleen Sweeny-Meacock Care Home 57 Category(ies) of Old age, not falling within any other category registration, with number (57) of places Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 32 persons requiring nursing care and a maximum of 25 persons requiring personal care may be accommodated at any one time. 27th February 2006 Date of last inspection Brief Description of the Service: Kestrel Grove is a private care home situated in a quiet residential area of Bushey Heath, Hertfordshire. Bus public transport facilities are accessible within a few minutes walk from the care home. The care home has a large car park at the front of the home for in excess of 20 cars. Shopping facilities and local amenities are situated in Bushey Heath Village, a short drive away. The home consists of a large, older house with two extensions, one on either side, in maintained grounds of about 6 acres. The extensions/wings have been constructed at different periods of time. The newest wing is found to the left of the main building and provides accommodation mainly for service users with personal care needs. The main house and part of the wing on the right are served by a shaft lift, while the wing on the left is served by a chair lift. The remaining part of the home is for the accommodation of service users requiring either nursing or personal care. The home is registered for 32 service users requiring nursing care and 25 service users needing personal care. Accommodation is provided in single rooms situated mostly on two levels. The service users share a number of communal areas. There is a main lounge and dining area in the main house and another lounge in the new wing. Mrs Kathleen Sweeney-Meacock manages the home with support from the proprietor Mr Paul Tripp. Prospective residents and others have access to information about the service provided by the care home. This is provided in from the care home’s website or in paper documentation. Information about the fees are accessible from the provider and/or from the website. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout a day and a half in November 2006. Two inspectors completed the inspection. The registered manager and the registered provider were present throughout the inspection. The inspection focussed on spending time talking with service users, and observing their interaction with staff and with other service users. Some visitors were also spoken too. Assessment as to whether requirements from the previous inspection had been met, also took place. Documentation inspected included, a sample of the service users’ care plans, complaints, and accident/incident records, the staff rota, and medication records. A variety of other records were also inspected. 23 National Minimum Standards (including key Standards) for Older People were inspected. The inspectors would like to thank the service users, the manager, and all other staff and the proprietor for their assistance in the inspection process. What the service does well: There is accessible comprehensive up to date information about the service provided by the care home recorded in a pictorial and written format on the care home’s website. Paper documentation of this information is also accessible within the care home. The care home has ‘homely’ features, with furnishings of quality. Service users spoke of the staff being caring, and of being very satisfied with the service provided. Examples of comments from service users included “couldn’t find any better”, “staff are very nice”, and “staff are helpful”. The registered person is fully involved in the service provided by the care home and is accessible within the care home during most days of the week. The registered manager is competent, approachable, motivated, and keen to continue to develop the quality of the service. It was evident that there were examples of several systems, which had been put in place and/or further developed, to ensure that there is on-going improvement in regard to the service provided to service users. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 6 Staff have a good knowledge and understanding of resident’s needs, and were observed to be very sensitive and respectful to residents during the unannounced inspection. Staffing numbers are adjusted and flexible to ensure that the assessed needs of service users are met. Feedback from residents in regard to the food served was that the meals were good and that the portions provided were ample. Care plans are generally comprehensive, accessible, and up to date, and regularly reviewed. 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. 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. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,3 and 6 (not applicable). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that residents have their needs assessed prior to moving into the care home. Information in regard to the service is accessible to residents and prospective residents and others. EVIDENCE: The care home has a website in which comprehensive information about the service provision is recorded, and regularly reviewed. A service user guide and the statement of purpose are accessible from the care home. Commission for Social Care Inspection, inspection reports are accessible in the care home and on the Kestrel Grove website. Care plans recorded evidence of a comprehensive assessment of the needs of residents. The registered manager or the deputy manager carry out the initial assessment of prospective service users needs, which includes a dependency assessment, and when required, a nursing care needs assessment. This forms Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 9 the basis of the care plan for daily living. A visitor confirmed that her relative had received an initial assessment of their needs by management staff prior to his admission to the care home. The registered manager confirmed that the assessment process continues when a service user is admitted to the care home. A service user spoke of having visited that care home prior to her admission. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that resident’s health, social, and personal care needs are set out in an individual care plan. There could be further development in some staff guidance to meet assessed needs of service users. Residents are treated with respect and their right to privacy upheld. Medication is stored and administered to residents safely. EVIDENCE: Care plans that were inspected, included evidence of comprehensive assessment of residents’ individual needs, which included, a photograph of the resident, personal information, including some recorded preferences such as preferred name. Other assessment information included eating and drinking needs, communication needs, daily routines, and activities. The care plans inspected recorded service users’ varied individual needs such as personal care needs, mobility needs, diet/nutrition needs, continence and Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 11 specialist medical needs, and staff guidance to meet those needs, and also evidence of those needs being regularly reviewed. The care plans inspected recorded evidence of being updated to reflect changing needs and current objectives in regard to health and personal care. The issue of development in assessment of service users sexuality needs was discussed with the registered manager and registered person. The registered manager spoke of plans to review ways to develop the present process of assessment of service users sexuality needs. Some recorded staff guidance to meet service users assessed needs, needs to be further developed. This includes one service user’s epilepsy needs. Recorded staff guidance needs to be further developed to ensure that there is a record of when an ambulance would need to be called, if following the administration of medication the symptoms did not improve. The use of bedrails was recorded in several care plans inspected. There needs to be further development in assessment (including risk assessment) of the use of bedrails, and there needs to evidence of agreement of their use, from the service users (if practicable) and/or their relatives/significant others. The assessment in regard to the use of bedrails needs to be carried out by a competent person, and be reviewed regularly. This was discussed with the registered manager. There was evidence that relatives/significant others are fully involved in the care plan, which includes its review. A relative read and signed her relative’s plan of care during the inspection. Not all the care plans inspected indicated that service users were involved in their care plan and its review. It is recommended that all service users sign their initial care plan, and that there is evidence that they are involved in all it’s review unless unable (or do not wish) to do this. Records, service users, and staff confirmed that service users’ personal care needs, and healthcare needs are assessed, and that staff guidance to meet those needs is recorded. A service user spoke of being offered a bath everyday, and that this was unhurried. She spoke of being able to ‘soak’ in her bath as long as she liked. Records indicated that service users have access to healthcare treatment and advice. These include access to chiropody, tissue viability nurse, optician, dental and physiotherapy care. An optician visited some service users during the inspection. A service user confirmed that she was supported in attending regular hospital appointments. Service users are registered with a GP. The care plans included risk assessments in regard to falls, risk of developing pressure sores, nutritional assessments and continence assessment. There was generally clear guidance to meet these assessed risks, particularly when assessed as being of high risk, but one care plan inspected recorded that a resident was at risk of developing pressures sores, but there was not specific Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 12 guidance in their care plan. The registered person needs to ensure that there is always recorded guidance to minimise identified risk of pressure sores. Staff confirmed that the care home has equipment necessary for the promotion of tissue viability. There was recorded evidence of some pressure area care recording charts that were located in accommodation areas of the home. The manager spoke of advice regularly being sought from the tissue viability nurse. The registered manager informed the inspectors that two service users had pressure sores, which they had had on admission to the care home, and that these were being treated appropriately. Photographs are used as a tool to monitor the progress of this care and treatment. Service users have access to a telephone. Service users preferred name of address is recorded in the care plans. Service users who kindly spoke with the inspectors confirmed that staff were respectful. Staff were observed during the inspection to be knowledgeable and understanding of service users privacy and dignity needs. A visitor spoke of her relative being offered choice. Records confirmed that service users are registered on the electoral role. The care home has a medication policy. Procedures are in place for the receipt, recording, storage, handling, administration and disposal of medication. The medication storage and administration systems were inspected. Medication is stored securely. The lead inspector spent some time with a registered nurse when she was administering medication. It was evident that the nurse had knowledge and understanding of safe medication administration procedures and was demonstrating these systems to another staff member. The registered manager reported that two service users self administered medication. There needed to be evidence of individual self medication procedures being in place and recorded. The manager developed these procedures following the first day of inspection and these were available for inspection on the second day of the inspection. Kestrel Grove Nursing Home DS0000022930.V317978.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. Arrangements are in place to enable residents to participate in activities of their choice, and to maintain contact with family/significant others, as they wish. Meals are varied and wholesome, and pleasantly presented. EVIDENCE: The care plans inspected recorded assessment of service users individual social needs and of their preferences in regard to activities. The care home had the weekly activity programme displayed in several communal rooms. The format of this could be improved i.e. larger print and pictures to make it more accessible to service users. The recorded activity programme for the week included a film show, art class, bingo, an entertainer, exercise to music and a cocktail party. Staff reported that other activities included ‘sing songs’, board games and listening to piano playing. The inspectors were informed that local Brownies visit the care home at Christmas. A carol concert takes place annually. The registered person is fully involved in the development and provision of the leisure pursuits for service Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 14 users; he confirmed that service users have the opportunity to make suggestions about activities. He and the registered manager spoke of the recent Halloween party that was held in the home. The inspectors were shown photographs of the event. Photographs of activities and events held in the care home were displayed in the care home. Service users who had attended the Halloween party spoke very positively about the event; one service users described the event as “amazing”. In the summer, the care home held a garden party/fete in celebration of Kestrel Grove’s forty years anniversary. Family/significant others, and service users participated in the occasion. There are televisions with large screens, and music systems in the communal lounge areas of the home. There was a singer who provided entertainment during an afternoon of the inspection. Several service users participated in this session and spoke of enjoying the entertainment. One resident reported that the quality of entertainment varied, and that she chose when to participate in an activity. It was not always clear what activities service users participated in when they did not wish to be involved in the general entertainment. The registered manager spoke of her plans to develop the provision of individual activities including reminiscence sessions with photographs. She spoke of plans to introduce a system that on admission service users bring with them photographs and other personal mementos. This is intended to be part of the admission procedure. Also the manager reported that she aims to improve the recording systems of individual activities. She spoke of how activity records had been developed since the last inspection. This is positive and recommended. The registered person spoke of the cultural needs (including. celebration of particular religious festivals) of service users being provided and supported by relatives and significant others. Christian festivals are celebrated in the care home. The inspectors were informed of there being annually a large decorated Christmas tree displayed in a prominent position in the care home. Following the inspection the registered person informed the Commission for Social care Inspection of the Jewish festivals acknowledged and celebrated in the care home. The inspectors were informed that a Catholic priest and also a vicar visit service users at their request regularly. The inspectors were informed that there is a visiting library service that visits the care home regularly. A service user spoke of receiving a newspaper and magazines regularly. A hairdressing service is also available to service users. It was evident from talking to residents that the provider’s dog was very popular. A resident spoke positively of the pet dog’s ‘visits’ to the care home including it’s visits to her room. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 15 A visitor took a service user out for the day during the inspection. A service user spoke of not having been out in the community for several months, and that that she would like to “go to the shops occasionally”. One service user said that she “ would like a companion”. Community participation particularly for those who do not have visitors to take them out is an issue that could be possibly developed. There were several visitors visiting service users during the inspection. Service users are able to receive visitors in private. The home also has several communal areas (including small communal areas) within the care home, which service users can access with their visitors. Records, observation and service users, confirmed that there were a significant number of visitors to the care home. It was evident from talking to service users that they were fully supported in bringing personal possessions including furniture with them when they are admitted to the care home. The inspectors were supplied with a copy of a four-week menu. This recorded varied and wholesome meals. Staff spoke of the residents being offered choice on a daily basis. A resident gave an example of a choice of meal that she had recently made. Records confirmed that a choice of meals and snacks were provided to service users. Special dietary needs including individual cultural/religious dietary needs were recorded in care plans inspected. Food preferences and were recorded. The registered person spoke of service users being enabled to have any particular preferred foods that they wished for (including particular food items that meet their cultural/religious needs), and he spoke of examples of purchasing specific food items for several service users. A service user spoke of keeping particular preferred food items in a fridge in her room. Staff confirmed that only fresh quality food was provided to service users. Eight residents ate in the dining area during lunchtime on the second day of the inspection. Some service users ate in their rooms or in the lounge areas. A service user spoke of choosing to eat in her room, and that this choice was supported by staff. Service users who kindly spoke with the inspectors were very positive about the food provided. The inspectors sampled the first course of the lunch provided on the first day of the inspection. This was presented in an attractive manner, and tasted very pleasant. Service users confirmed that they enjoyed this meal. Meals were observed to be unhurried and service users were provided with support by staff as and when they needed. Residents were offered a choice of fruit at the end of the meal. The care plans inspected recorded evidence of nutritional assessment and there was evidence of staff guidance to meet these assessed needs. Staff who spoke to the inspectors had understanding of service users individual nutritional support needs. A care plan included ‘swallowing’ guidelines, which had been developed by a speech and language therapist. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 16 Hot and cold drinks were offered throughout the day. Drinks were accessible at all times in the communal areas. There is an accessible drinking water dispenser. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that complaints are dealt with promptly and effectively, and that residents are protected from abuse EVIDENCE: The care home has a complaints procedure. This is accessible in the service user guide, and the statement of purpose documentation and from the care home’s website. Complaints records were inspected. There had been two complaints within the last year. Records confirmed that these were taken seriously and appropriate action taken to resolve the complaints. A service user said that she “ would talk to the manager if she had a concern”. The care home has a protection of vulnerable adults procedure and a copy of Local Authority guidance. The registered person should obtain a copy of the up to date new Local Authority Safeguarding Adults procedure/guidance. This was discussed with the registered manager. Staff who spoke with the inspectors were knowledgeable and understanding of the appropriate recording and reporting procedures in response to an allegation or suspicion of abuse. The registered manager reported that staff receive protection of vulnerable adults training. Kestrel Grove Nursing Home DS0000022930.V317978.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the care home is suited for its stated purpose, and is generally well maintained, and very clean. There remains an issue of access to some areas of the care home for those that have significant mobility needs. The home provides private accommodation for each service user, which is furnished and equipped to provide comfort and privacy. EVIDENCE: The care home premises consists of a large detached house located in considerable grounds. Over the years there has been extensions added to the building. The garden is well maintained. The home is generally well decorated. There are some areas i.e. the main kitchen including the room containing the fridges and freezers in which the décor could be improved, and Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 19 there were areas of the carpet in the main house that were worn and in some places ruffled i.e. near the upstairs shower room in the main part of the house, and in the main dining room area. The registered person spoke of the ongoing programme of maintenance, and the plans for redecoration of some areas of the care home. The home has a passenger lift in the main part of the house. There is a stair lift and a wheelchair lift in the home. This mobility equipment was in working order; two service users kindly (with staff support) demonstrated the stair lift and wheelchair lift in action. The inspectors observed that some service users who have their rooms on the ground floor of the right wing and are wheelchair users and have to go outside through a side door of the wing to access the lounge and dining area of the main part of the home. This is due to there being several of stairs between the ground floor on the right wing and the level where the lounge and dining area are situated. This was acknowledged during the previous inspection. Staff were observed to ensure that service users are wrapped up well before venturing outside to access the communal area of the main house. Staff and some service users spoke of the difficulties presented when the weather was particularly wintry, which sometimes they said, led to service users remaining in their bedrooms. A relative’s feedback questionnaire recorded that they considered this to be quite a significant access issue. Some service users accommodated on the lower floor of the new wing could also experience a similar difficulty if they are unable to use the stair lift or stairs. The registered person should continue to review this access issue and continue to aim to ensure that service users with significant mobility needs are accommodated in areas of the care home in which they can easily access communal areas in the main area of the house. A suitably qualified person such as an Occupational Therapist could be contacted in regard to advise about the environment and possibly carry out an assessment. Service user bedrooms that were inspected were generally large, light and airy. There was evidence of these bedrooms being personalised. Service users kindly showed the inspectors items of furniture, pictures and other personalised items that they had brought with them from their previous home. Service users spoke of being happy with their rooms, and described the home as “always being warm”. The bedrooms varied in regards to the type of floor coverings. Some rooms had alternative flooring to carpeting. The need for risk assessment of this flooring was discussed with the registered manager. Following the first day of the inspection the registered manager completed risk assessments in regard to assess and minimising any possible slip hazard of this flooring. An electric adjustable bed in one bedroom was not in working order on the first day of the inspection. The lead inspector was informed that there were plans for this to be repaired. The bed had been repaired by the second day of the inspection. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 20 The care home is clean and pleasant. There are several domestic staff that are employed in the care home. These staff were working during the inspection, and it was evident that significant and appropriate cleaning is carried out in the care home. Laundry facilities are located away from food storage and food preparation areas. The washing and the clothes drying machines are industrial machines. Hand washing facilities are located throughout the care home. Staff were observed to wear protective clothing including disposable gloves and aprons. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 21 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): Standard 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that staffing numbers and skill mix meet the needs of the residents. There needs to be recorded evidence that robust recruitment and selection procedures are carried out at all times to ensure that residents are protected. Staff receive appropriate training to ensure that they have the skills and competency to meet the needs of residents. EVIDENCE: From observation, inspection of the staff rota, and from talking to staff and to service users the inspectors judged that there were sufficient staffing numbers and skill mix of qualified/unqualified staff to ensure that the needs of service users were met. Care staff confirmed that there was sufficient staff on duty, to ensure that the general atmosphere of the home was relaxed and unhurried. The registered manager reported that the ratio of care staff (day and night staff) to service users varied in accordance to the assessed needs of the service users, and that she had recently introduced ‘twilight’ staff to help with assisting service users to bed. She confirmed that she regularly increases staff numbers to ensure that assessed needs of service users are met at all times. There were three qualified nurses (including the registered manager) on duty during the inspection. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 22 The home also employs domestic staff, cooks, and gardeners/maintenance persons. These staff were on duty during the inspection. Staff who spoke with the lead inspector spoke of the care home as being a very “friendly” atmosphere, and that staff “couldn’t find a better care home to work in”, and that “it was a very good place”. Service users who kindly spoke with the inspector were very positive about the care staff. They spoke of them being ‘helpful’, ‘caring’ and ‘kind’. Staff who spoke with the inspectors were very knowledgeable of service users needs, and interacted with them in a sensitive manner. Staff were aware of when and how to report service users changing needs. Staff reported that the staff ‘turnover’ in the care home was very low, and that the staff team worked well together. Several care staff that spoke with the lead inspector had been employed by the home for many years. Staff duties were recorded on shift planners. Staff meetings including meetings for trained staff, take place. The registered manager informed the inspectors that all care staff have completed or are in the process of completing NVQ level 2 or 3 care courses. Eight staff personnel files chosen at random were inspected. There was some documentation not accessible in the files. These included references, an application form and no evidence of an enhanced CRB in regard to one staff. The registered person spoke of there not being references for some staff that had been employed in the care home for many years. This should be indicated in the individual staff personnel files. The registered person needs to ensure that all required staff personnel documentation is available for inspection. This was a previous requirement. It is recommended that the content of all the staff files are reviewed and that any missing information and documentation is obtained and included in these staff files. The registered manager reported that staff receive weekly training sessions, and had recently received moving and handling training, health and safety training and food and hygiene training. Staff who kindly spoke with the lead inspector confirmed that they received “lots” of training appropriate to their role and responsibilities. This training includes using equipment such as ‘hoists’ for moving and handling. Other training includes nutrition training, continence training, supporting people with dementia, and training in managing residents who might challenge the service. The registered manager reported that the deputy manager had particular expertise in the care of service users who have diabetes. Staff spoke of receiving a comprehensive induction programme of training, which included ‘shadowing’ more experienced staff for a significant period of time. A completed staff induction record was available for inspection. The care home has a training room where ‘in house’ staff training takes place. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 23 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): Standard 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident’s benefit from an experienced and competent management approach to the care home. Arrangements are in place to ensure that the service provided by the care home is monitored and improved as necessary to meet the aims and objectives of the home. Resident’s financial interests are safeguarded, and the health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 24 The registered manager is a trained nurse and is experienced in working with older persons needing care and support. She reported that she had recently received her certificate in regard to completing NVQ level 4-5 in management course. It was evident from speaking with the manager that she had knowledge and understanding (and a great interest) in of the conditions /diseases associated with old age. She spoke of having recently completed a dementia care training course. The manager was observed to interact with service users and visitors in a positive, friendly and respectful manner, and it was evident that she knew them well. The manager spoke of the systems that she had introduced since becoming manager of the care home and of the future ideas and plans she had for continuing to develop and improve the service. The manager works a variety of shifts. She spoke of completing regular ‘spot checks’ to monitor the care home at night. Service users who spoke with the lead inspector were aware of whom the manager was. Records, staff and visitors confirmed that there are clear lines of accountability within the home and with the proprietor. The registered manager informed the inspectors that the registered nurses were key workers for the service users. Records confirmed that a resident had an accident in September 2006, which resulted in hospital treatment for a service user needed to have been reported to the Commission for Social Care Inspection. The registered person needs to ensure that the Commission for Social Care Inspection is notified of all events recorded in the Regulation 37 of the Care Homes Regulations 2001 Guidance. The home has a quality assurance policy/procedure. Satisfaction survey questionnaires about the service were available for inspection. The management staff had audited these and an action plan developed. An annual development plan/business plan was available for inspection. It was evident that records are regularly reviewed. It is recommended that service users have the opportunity to participate in regular resident meetings. This was discussed with the registered manager. The registered person informed the inspectors that the care home does not manage the monies/financial affairs of service users. Generally relatives/significant others manage service users monies if they are unable to do this themselves. A service user confirmed that her relative manages her finances. The registered person reported that invoices for hairdressing, newspapers, and other personal items were supplied to those that manage the service user’s finances. Records informed the inspector that checks and servicing of systems within the care home are carried out as required. These include electrical and gas system checks, passenger lift, specialist baths, and hoist safety checks. Fridge /freezer temperatures are monitored. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 25 Required fire checks and drills are carried out. The care home has an up to date fire risk assessment. Fire exits are signed. The proprietor reported (and it was observed) that he has met the previous inspection requirements in regard to having had appropriate automatic devices installed to doors within the care home including service user bedroom doors. He confirmed that the previous inspection requirement in regard to risk assessment and control measures being in place for of the sash windows had been met. The hot water tap in the visitors/staff bathroom was producing very hot water. The registered person needs to ensure that this is risked assessed and that appropriate measures are put in place to minimise the risk of scalding. The inspectors noticed a slight smell of gas in a kitchen area. The registered person reported that this would be assessed. The home has an accident procedure, which was displayed. Records confirmed that accidents/incidents are recorded, and that these are regularly reviewed. Call bells are accessible to service users and were in working order. The registered manager reported that she had put in place a system of wheelchair checks and recorded staff guidance with regard to the use of wheelchairs. The employer’s liability insurance certificate was displayed and up to date. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 26 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 2 8 3 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 3 X X X X 3 X 3 STAFFING Standard No Score 27 4 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12(1)(a) (2), 13 (4) (c), 14(1) (a) • Requirement Timescale for action 01/04/07 2 OP7 3 OP29 Recorded staff guidance in regard to meeting one service user, (who has epilepsy needs) to be further developed to record when an ambulance would need to be called following the administration of medication in response to a particular medical need. • The registered person needs to ensure that there is recorded individual guidance to minimise identified risk pf pressure sores in regard to one service user. 12, 14 There needs to be further 01/03/07 development in assessment (including risk assessment) of the use of bedrails and there needs to evidence of agreement from the service users (if practicable) and/or relatives. This assessment in regard to the use of bedrails needs to be carried out by a competent person, and be reviewed regularly. 19(1)Sche The registered person must 01/03/07 DS0000022930.V317978.R01.S.doc Version 5.2 Kestrel Grove Nursing Home Page 28 d2 4 OP31 37 5 OP38 23 ensure that all members of staff have appropriate references and CRB checks as per Schedule 2 of the Care Homes Regulations 2001. Previous timescale 30/06/06 not met. The registered person needs to notify the CSCI of events recorded in the Regulation 37 of the Care Homes Regulations 2001 Guidance. The hot water tap in the visitors/staff bathroom was producing very hot water. The registered person needs to ensure that this is risked assessed and that appropriate measures are put in place to minimise the risk of scalding. 01/02/07 01/02/07 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 2 Refer to Standard OP7 OP12 Good Practice Recommendations It is recommended that all service users sign their initial care plan, and they are involved in all it’s reviews unless unable (or do not wish) to do this. • The format of the activity programme could be improved i.e. larger print and pictures to make it more accessible to service users. • It is recommended that the registered manager develop and provide evidence of the provision of individual activities for service users who do not wish to join in the general entertainment and to also improve the activity recording systems. • Community participation particularly for those who do not have visitors to take them out into the community could be reviewed. The registered person should obtain a copy of the up to date Local Authority Safeguarding Adults DS0000022930.V317978.R01.S.doc Version 5.2 Page 29 3 OP18 Kestrel Grove Nursing Home 4 OP24 5 OP33 procedure/guidance. • The registered person should continue to review the access for wheelchair uses to the main house from the ground floor of the right wing of the care home, and continue to aim to ensure that service users with significant mobility needs are accommodated in areas of the care home in which they can easily access communal areas in the main area of the house. • A suitably qualified person such as an Occupational Therapist could be contacted in regard to advise about the environment and possibly carry out an assessment. It is recommended that service users have the opportunity to participate in regular resident meetings. Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kestrel Grove Nursing Home DS0000022930.V317978.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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