Inspection on 27/02/06 for Kestrel Grove Nursing Home

This inspection was carried out on 27th February 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 01/11/06

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 Mr Ram Sooriah Unannounced Inspection 27th February 2006 10:15 am 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.V284025.R01.S.doc Version 5.1 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.V284025.R01.S.doc Version 5.1 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.V284025.R01.S.doc Version 5.1 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. 5th July 2005 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. It is situated on a small road off the busy Common Road (A409). It is accessible by public transport, which passes on the main road or by car. It 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 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 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 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. The home is managed by Mrs Kathleen Sweeney-Meacock with support from the proprietor Mr Paul Tripp. At the time of the inspection there were 56 service users in the home. Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by Gail Freeman, regulation manager, and Ram Sooriah, regulation inspector. In this report the term ‘inspectors’ refers to both of them and the term ‘inspector’ refers to Ram Sooriah. This is the second unannounced inspection for the period 2005-2006 and it started at about 10:30 and finished at about 16:30 The inspectors toured part of the premises, looked at a sample of records, talked to service users, a few visitors, the proprietor, the manager and some members of staff. They were also able to check for compliance with past requirements and recommendations. The Commission has received seventeen completed comments cards from service users and one from relatives/visitors. These have been used where possible in this report. All the respondents said that they are well cared for and the overwhelming majority said that they like living in the home. The inspectors would like to thank the service users, the manager and all her staff for a kind welcome to the home and for their cooperation and assistance during the inspection. What the service does well: What has improved since the last inspection? Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 6 The content and standard of the care plans have improved. Records with regard to pressure sores are now more comprehensive. The home has introduced a falls risk assessment for all service users to address the risk of falls. The records with regard to the care of wounds/pressure sores have improved and are now more comprehensive. The home has introduced systems to ensure that service users or their representatives are consulted about the care plans. The standard of cleanliness has improved in the home. There were no odours and the standard of cleaning was very good. The manager has made risk assessments with regard to having items such as wheelchairs and laundry skips in the corridors, which might have been obstacles to service users. As a result she has been able to clear most of these items from the corridor. The management of medicines has improved to ensure the safety of service users. New clinical areas have been established on some floors for the safe storage of medicines. More of these are being set up for each floor/area of the home. 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. Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 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.V284025.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 The needs of service users are appropriately assessed to ensure that the needs are clearly identified for care plans to be put in place to meet these needs. EVIDENCE: All service users have a pre-admission assessment prior to the home, which is carried out by the manager or her deputy. Copies were on file for inspection. Service users or their representatives have the opportunity to visit the home prior to admission of the service user to look at the home and to ask questions. Care plans now have a comprehensive and detailed assessment of the needs of service users. Care plans were in place in cases where service users’ needs have been identified. The home has good staffing levels. However members of staff are also attentive to the needs of service users and take into consideration the choices of service users. This was evidenced by service users who were complimentary about staff in the home. Although the management and staff seemed dedicated and willing to do whatever possible to meet the needs of service users, they may at times be Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 9 hampered by difficulties, which may be caused by the nature of the environment of the home. The home being an old converted house does provide a homely environment and has its own individual and interesting characteristics. It is positive that these have been preserved during the years. There are however some drawbacks. For example service users who are wheelchair users and who are accommodated on the ground floor of the right wing (when facing the front of the home) cannot access the dining room from inside the building. They have to go outside through a side door to come through the front door of the home to reach the lounge and dining area. This is because there is a set of stairs between the ground floor on the right wing and the level where the lounge and dining area are situated. Service users accommodated on the lower floor of the new wing also experience a similar difficulty. There is a chair lift, but this has limited use for service users who are wheelchair users or for those who have difficulty maintaining a straight posture to sit on the chairlift. The manager however stated that only service users who can manage the stair-lift are accommodated on that level and that service users/relatives are provided with information about these areas and other areas where there are vacancies and that the service users/relatives can make choices about the rooms from the information provided. Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 9 Care plans are comprehensive and address the needs of service users. The healthcare needs of service users are being met in the home. The management of medicines is being carried out in a satisfactory manner to ensure the safety of service users. EVIDENCE: A sample of care plans was inspected at random. These were detailed and included all aspects of health, personal and social care needs. The manager said that she was in the process of monitoring entries and this was evident on inspection. Gaps in the care records were identified and the action needed to rectify the gaps was clarified. The care plans inspected were reviewed on a monthly basis and the last review had taken place in February. It was observed that a number of care plans had been signed by the representatives of service users. This was positive and showed that the relatives of service users were being involved in drawing up and in discussing care plans. Care plans contained comprehensive records about pressure sores. There were photographs in place to monitor the healing of wounds/sores. A range of pressure relief equipment was noted to be in use in the home, and the equipment in use for individual service users was recorded in the care records. Since the last inspection the home has introduced a Falls Risk Assessment, Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 11 which were appropriately completed. In cases where service users were at high risk, care plans were in place to prevent falls. A continence assessment has also been introduced for the service users in the home and this was in place in the care plans of service users. At the time of the inspection, the home still used chair pads on the chair of service users. It was not clear if this incontinence aid was being used as a result of the individual continence assessment of the service users. Incontinence aids which are used to manage the incontinence of service users should in the first instance be based on their individual needs’ assessment and should be discreet enough to ensure the modesty, privacy and dignity of service users. The manager stated that she would be reviewing the use of the chair pads in the home. If indeed there was a problem with managing the incontinence of service users, consideration should be given to seeking the advice of the continence advisor from the local PCT. The inspector looked at the management of medicines in the home. He noted that the home was maintaining an appropriate policy with regard to ordering medicines and checking these when they were received. Copies of the monthly scripts were also kept. The amount of medicines received into the home was also recorded. All the medicines sheets, which were randomly inspected, were signed as appropriate. The home has a number of residents who were on controlled drugs. These were also being appropriately managed and the manager has introduced a system for checking the amount of the controlled drugs at monthly intervals. Since the last inspection, there has been the development of a number of clinical rooms on nearly all the floors/units. These were clean, airy and tidy. Signs were on the doors in cases where oxygen was being stored in these rooms. Efforts made by the manager and her staff to meet the previous requirements are commended. Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The home provides a range of activities to meet the needs of service users. The home encourages the relatives and friends of service users to visit them and makes attempts to involve service users in the local community. The home provides appropriate meals to service users, taking their choices and preferences into consideration. EVIDENCE: The home had a programme of activities, which was on the notice boards of all the units. There was a planned activity for nearly every day of the week, except for the weekend. The manager stated that over the weekend staff carries out activities on a one-to-one basis and that a number of service users receive visitors. She added that about 50 of service users do not have relatives/visitors and the inspector therefore concluded that the weekend activities are particularly important for those who do not receive any visitors. The inspectors also observed one-to-one interaction of staff with service users on the day of the inspection. Fourteen respondents to comment cards said that they were satisfied with the recreational and social activities in the home and three said that they are sometimes happy with these. With regard to outings, the manager clarified that outings currently occur mostly on an individual basis when carers sometimes take service users to the local shops in wheelchairs. The home also uses dial-a-ride to arrange for service users to go shopping or to go out. The proprietor added that he was considering buying a mini-bus to facilitate outings for service users. Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 13 During the course of the inspection there were a number of visitors to the home and the inspectors noted that they were all welcome and offered refreshments. Most of them elected to see the service users in the bedrooms of the service users. The inspectors were also informed that most of the residents are from the local community and that as such the home maintains a close link with the community. The inspectors observed lunch being served in the home. A few service users used the communal dining areas, and some service users had their meals in their rooms. There was evidence that care staff had gone round to ask service users about their choices. Although there was only one choice for lunch recorded on the menu, the manager stated that meals in the home was very flexible and that service users could request for anything and that the home would attempt to provide this. The kitchen was clean and tidy. The home has separate preparation rooms for resident trays with dedicated staff to carry out this task. As a result the inspectors concluded that the provision of meals in the home was flexible and that efforts are made to ensure that the wishes and choices of service users are respected. The hotel services in the home were also judged to be excellent. Fourteen respondents to comments cards like the food and three said that they sometimes like the food. Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 14 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): 18 The home has ensured that there are systems in place to deal with allegations and suspicions of abuse in an appropriate manner. EVIDENCE: One new appointed member of staff was able to communicate that if he/she has concerns about care practices in the home he/she would be able to contact the manager, the proprietor or the Commission to voice these concerns. The home has not had any cases of allegations or suspicions of abuse since the last inspection, but the manager was aware of procedures to follow in these cases. The home has arranged for staff to have training on abuse and on the protection of Vulnerable Adults. Conversation with a number of service users indicated that they would approach the manager or the person in charge if they had any concerns. Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 15 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 The home provides a comfortable and homely atmosphere for service users. The layout of the home at times could provide some difficulties with regard to the care of service users with poor mobility. EVIDENCE: The grounds of the home were maintained and in keeping with the time of the year. The exterior of the home was also in good condition. The home was in a good state of decoration and there was evidence that a number of areas have been recently redecorated and refurbished. For example the carpet in the corridor on the ground floor of the right wing has been replaced and the walls have been repainted. The inspectors recognised the efforts that the proprietor and the manager make with regard to maintaining the premises to such a good state of redecoration. During the last inspection, it was recommended that the home arrange for an assessment of the premises by a competent person such as by an occupational therapist. Some of the reasons for this are detailed in section 1 of this report. The inspectors have also noted that the bathing facilities on the new wing are not very convenient for service users who have high dependencies. All the rooms on that unit have en-suite bathrooms with a bath, toilet and washbasin. Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 16 The bath however is not accessible by a mobile hoist and is placed against the wall. Some of the baths have fixed hoists. This is manageable for service users with low dependencies, but it must be taken into consideration that staff would not be able to attend to them on either side of the bath. However service users with higher dependencies have to be transferred with a mobile hoist to their wheelchair, wheeled to their bathrooms and then from the wheelchair transferred into the bath using the fixed hoist into the bath. Part or all of the process is again repeated after the bath. It must also be noted that it is not possible to attend to service users on either side of the bath, as it is situated against the wall. It was observed that some corridors have a grab rail on one side of the wall. This could lead to service users experiencing some difficulty if for example there are two service users walking in different directions, using the grab rail and having to pass each other. In a few areas of the home there were no grab rails in the corridor, such as in some parts of the corridor of the ground floor of the right wing. It is therefore for the above reason that the inspectors strongly recommend an assessment of the premises by an experienced person such as an occupational therapist with regard to equipment and adaptations in place to manage the disabilities of service users and their care. The inspectors viewed a sample of bedrooms, which were all appropriately decorated and furnished. There was also a good degree of personalisation of the bedrooms, which made them homely and individualised according to the needs of the person occupying the room. The home has a dedicated team of cleaners. The standard of cleaning was very good and there was no odour in the home. The inspectors have noted the progress that has been achieved in this area. Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 The home has good staffing levels and provides appropriate training to ensure that staff are sufficiently trained and skilled to meet the needs of service users. Recruitment procedures were not very thorough to ensure that all staff have had appropriate references and checks prior to being appointed in post. EVIDENCE: The home continues to provide an excellent ratio of care staff to service users. There are 2 trained nurses and 20 carers in the morning; and 2 trained nurses and 12 carers in the afternoon. There is an additional carer from 1600 –2200 and at night there are 1 trained nurse and 5 carers. The manager is mostly supernumerary in the mornings. The numbers of staff is reflected in the amount of attention that staff are able to offer to service users. For example it is possible to feed most service users who need to be fed, around the same time and not having to wait for long times before a carer becomes available to feed them. Apart from the excellent ratio of care staff, there is also a team of ancillary staff to support the delivery of care. Comments cards showed that all respondents said that staff treat them well. The manager stated that more than 50 of the care staff are trained to NVQ level 2 and that more would be enrolling on the NVQ course. The inspectors were informed that the home has its own induction programme and that new staff have basic training in fire training, manual handling and health and safety. More in depth training in the mandatory areas is provided when these are arranged for all staff to attend. The home has a dedicated training room and the manager stated that there are dedicated days for training, when guest speakers/trainers are invited to the home. There was evidence that training in a number of areas have been Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 18 provided for staff. There was evidence of training to manage aggressive behaviour and the manager showed the inspectors a training course on dementia that is going to be cascaded down to care staff. There was also a range of videos on a number of subjects that can be used to train staff. The inspector was forwarded the training schedule/mapping for a cross section of staff. The home has a computerised system, which is used to prepare its training programme. The individual training needs of staff are entered on the system and the period of training and course are identified. A planner is then produced highlighting when the training is due and the urgency of the training by the use of different colours. The inspector looked at the personnel files of three members of staff. The members of staff have been employed for some time in the home and the latest member of staff was employed in 2004. The inspector was unable to see written references for any of the members of staff and the member of staff appointed in 2004, albeit an ancillary member of staff has not had a CRB check. Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 19 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 manager is competent and able to discharge her responsibilities fully. The home has a quality assurance procedure in place. The home has little involvement in the management of the personal monies of service users, but where that is necessary, appropriate systems are in place to facilitate that. Service users are in the main safe in the home. One area was identified which needed to be addressed to ensure the full safety of service users. EVIDENCE: Since the last inspection the manager has completed the Registered Manager’s Award. She has demonstrated that she was committed to improving the service by addressing the requirements identified during the last inspection. She talked with enthusiasm about other things that she wanted to develop in the home. Staff and service users were all aware who the manager was and stated that they would approach her if they had problems. The comments cards showed that the majority of respondents knew who to talk to if they Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 20 were unhappy about the care of the service user. Three respondents said that they at times would like to be involved in decision making within the home. The proprietor has devised a quality assurance procedure for the home. This includes a number of audit areas, which are carried out either by the manager or the proprietor on an annual basis for quality control. The home has a range of policies and procedures, which according to the proprietor are reviewed annually. The inspectors were informed that the home has recently carried out a satisfaction survey and that the home has just received the questionnaires back, from which a report would be compiled. A copy of the analysis report was forwarded to the Commission after the inspection and action plans were being drawn to address the issues identified from the survey. On the whole, the home scored mostly good and excellent for the service that it provides. The proprietor stated that service users’ personal monies are not managed by the home, and that there is a facility for safe keeping if that is required. In cases where service users need to purchase something that they need, or when minor expenditures need to be made, there is a possibility for the home to support service users in this aspect, and a bill is then sent to the service user or to his/her representative. The inspector on this occasion did not look at all the safety certificates in place in the home. During the tour of the premises, the inspectors noted that some of the sash windows could be opened to such an extent that a person could easily fit his body through the opening. The following is an extract from a Local Authority Circular on the Health and Safety Executive website addressing the subject of falls from windows: “ A risk assessment should consider the needs of the service users and look carefully at all foreseeable situations which could give rise to risk. A legal duty is owed to psychiatric and other service users for management to take reasonably practicable steps to minimise the likelihood of service users injuring or killing themselves. (point 15, FALLS FROM WINDOWS IN HEALTH AND SOCIAL CARE, LAC 79/6; http:/www.hse.gov.uk/lau/lacs/79-6.htm)”. As a result of the above the registered person must ensure that appropriate risk assessments are in place with regard to the sash windows and to the extent that they open. During the last inspection, the inspector noted that a number of bedrooms’ doors were being held open by wooden door wedges. This was again observed during this inspection. The use of door wedges could prevent doors from closing in cases when the fire alarm has been triggered and therefore putting people at risk. The proprietor stated that he has started dealing with the requirement with regard to having appropriate automatic devices holding the doors, in cases when these are left open. There have however been some complications because of the nature of the doors, which would require that Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 21 some of the doors be replaced. The inspectors acknowledged the efforts of the provider in meeting this requirement and have set a new timescale for this requirement. Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X 3 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 3 X 3 X 3 X X 2 Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 23 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 OP29 Regulation 19(1) Sched 2 Requirement The registered person must ensure that all members of staff have appropriate references and CRB checks as per Schedule 2 of the Care Homes Regulations 2001. The registered person must ensure that the practice of using door wedges to keep bedrooms doors open is replaced by the use of an automatic door closure device, which will be triggered by the fire detection system (Previous requirement, timescale of 30/11/05 not fully met). The registered person must ensure that there are risk assessments, including the control measures in place, with regard to the extent of the opening of windows in the home. Timescale for action 30/06/06 2. OP38 23(4) 31/08/06 3. OP38 13 (4) 30/04/06 Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 24 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 OP22OP4 Good Practice Recommendations Strong consideration should be given to an assessment of the premises and the provision of disability equipment in the home by a suitably qualified person such as an Occupational Therapist, to ensure the suitability of environment of the home with regard to meeting the changing needs of service users. It is recommended that the practice of placing chair pads on the chairs of service users be reviewed, subject to the individual continence assessments and the provision of needs-specific services in agreement with the individual service user/representative. 4. OP8 Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Kestrel Grove Nursing Home DS0000022930.V284025.R01.S.doc Version 5.1 Page 26 - 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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