Inspection on 05/07/05 for Kestrel Grove Nursing Home

This inspection was carried out on 5th July 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kestrel Grove Nursing Home 01/11/06

Kestrel Grove Nursing Home 27/02/06

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 Ram Sooriah Unannounced 05 July 2005, 12:45Ppm 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 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 G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Kestrel Grove Nursing Home Address Hive Road Bushey Heath Herts WD2 1JQ 020 8950 4329 020 8950 8074 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Paul Martin Tripp Mrs Kathleen Sweeney-Meacock CRH N Care Home with nursing 57 Category(ies) of OP Old Age 65 Years and over registration, with number of places Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24th January 2005 Brief Description of the Service: Kestrel Grove is a private care home situated in a quiet residential area of Bushey Heath, Hertsforshire. 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 accomodation mainly for service users with personal care needs. The remaining part of the home is for the accomodation 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. Accomodation is provided in single rooms situated mostly on two levels. The main house and 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 G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on a Tuesday. It started at about 12:45pm and finished at about 7:30pm. It was the first of the two statutory inspections for the period 2005-2006. During the course of the inspection the inspector had the opportunity to speak to service users, visitors to the home, the proprietor, the manager and some of her staff. He was also able to tour the premises, observe care practices in the home and inspect a sample of records. What the service does well: What has improved since the last inspection? The manager stated that she has been working to update care records. On inspection, it was noted that the care plans, which have been updated, were generally comprehensive. The manager and her staff seemed committed to training. The manager has developed a room in the basement of the home as a training resource room. A separate clinical room was being developed which would free the manager’s office. Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 6 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 G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 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 standard(s) 3 and 4 Some of the assessments of the needs of service users were comprehensive but others could have been more comprehensive to ensure that the needs of service users were clearly identified. The needs of service users were generally being met by the home. EVIDENCE: The inspector looked at four care plans. He noted that a service user who was recently admitted to the home had had a pre-admission assessment by the manager. This was generally comprehensive. Once service users were admitted to the home their needs were more thoroughly assessed to ensure the completion of care plans when needs have been identified. The different sections of the assessment, which address the various needs of service users, were however not always completed comprehensively. For example sections on emotional wellbeing, mental state and cognition, and likes and dislikes were not always completed. The manager agreed that the needs assessments of service users were not always comprehensive and she said that she has been working to make the care plans more comprehensive. The inspector indeed noted an improvement in the care plans where the manager has been involved. Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 9 Service users and visitors that the inspector spoke to, were pleased with the level of care and attention that service users receive in the home. The inspector noted evidence, which demonstrated that the home makes every effort to meet the needs of the service users. This for example included the staffing level, which was above levels recommended by tools such as the residential forum tool; the fact that service users were seen by a number of healthcare professionals when that was required; and the appropriate provision of meals and equipment for service users. The home has a new wing, which accommodates people requiring personal care. It is recommended that the provider continues to review the needs of service users who are accommodated there so as to ensure that their needs can continue to be appropriately met in that location. In particular, consideration should be given to an assessment of the premises and facilities in that part of the home by a suitably qualified person such as an Occupational Therapist, to ensure the suitability of that part of the home with regard to meeting the changing needs of service users. Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 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 standard(s) 7,8,9 and 10 Care plans were mostly comprehensive to ensure that the needs of service users, including the healthcare needs were being met. However service users or/and their representatives were not always consulted about the care plans. Although the management of medicines in the home was mainly appropriate, there were a few issues identified which need to be addressed to ensure the safety of service users at all times. EVIDENCE: Service users care records were kept in filing cabinets and were in good order. Care plans were in place in cases where needs of service users have been identified. The home also has a number of risk assessments such as pressure sore risk assessment, nutritional risk assessment and a manual handling risk assessment. The care plans and risk assessments were generally reviewed monthly. The inspector noted that not all service users had had a comprehensive falls risk assessment as per sub-standard 7.3 and as per standard 6 of the National Service Framework for Older People. From the four care records inspected the inspector noted that there was not always evidence that service users or that their representatives were involved in drawing up and in reviewing the care plans and risk assessments or the reason why that was not possible. The registered person must ensure that Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 11 service users or their relatives are involved in drawing up and in reviewing the care plans and noting the reasons when this is not possible. All service users presented as clean and appropriately dressed. The home uses the Waterlow Score to assess service users at risk of pressure sores. Those who were at risk had care plans in place and equipment for pressure relief was also in place. The home has a range of pressure relief equipment, which was in use depending on the needs of the service user. The inspector noted that the equipment used for pressure relief was not always recorded in the care records as evidence that service users were being appropriately cared for with the right equipment. The inspector looked at the care records of a service user who had pressure sores. There were regular wound assessments of the sores and there was evidence that the tissue viability nurse was involved in the management of the sore. Although photographs of the sores were taken in the past there were no recent photographs or wound mapping. The provider stated that this was because the sores were healing. However, the inspector recommends as a matter of good practice, and to demonstrate that progress is being made with regard to wound healing, that photographs are taken or that wound mapping is carried out at least monthly. The home also caters for a number of service users who are incontinent. The inspector did not see an individual continence assessment in place in the care records of service users. There were plans at times to manage incontinence but these did not always make clear the incontinence aids being used, the frequency of toileting and change of incontinence aids. The inspector noted the use of chair pads on most of the chairs of service users. However, recent research and guidance (e.g. The Department of Health (2000). Good Practice in Continence Care; DH (2001). Essence of Care.) advise on an individual approach to manage incontinence based on an individual continence assessment, by the provision of incontinence supplies which are specific to the needs of the individual while promoting privacy, dignity and modesty of service users. It is therefore recommended that the practice of placing chair pads on the chairs of all service users be reviewed, subject to individual continence assessments and the provision of needs-specific services. The inspector spoke to staff and the manager who reported a good service from the GP. The care records also showed that service users were referred to a range of healthcare professionals as and when that was necessary. Medicines were inspected. Records about medicines were generally appropriate with a few omissions of signing or of a code not having been used in some medicines charts. The inspector observed that nurses took the trolley with them when they administered medicines and that medicines were administered to one service user at a time on most occasions. There was one occasion when the inspector observed medicines not being administered to service users one at a time. This is not good practice and could increase the potential for service users to be administered medicines prescribed for others. Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 12 The inspector noted that the instructions on the label of a medicine for a service user were different from the instructions on the medicines chart. There was at least one medicine, which was discontinued by staff in the home. It is recommended that medicines, which are discontinued, are signed and dated by the GP. Medicines were kept secure on most occasions except when the inspector saw that a cupboard containing enemas and an eye drop was left unlocked. Service users and visitors stated that staff in the home were supportive and kind. The inspector observed that staff attended to the personal care of service users in closed bedrooms and that they related appropriately to the service users. All service users were dressed appropriately and looked well groomed. In addition to phone sockets in each bedroom and a system which enables internal calls, the home has portable phones, which can be used by service users who are in their bedrooms to make and to receive phone calls. There is also a pay phone, which is mostly used by staff use. Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 The home provides activities, which generally meet the expectations and preferences of service users. The home provides wholesome and appealing meals for service users taking their choices into consideration. EVIDENCE: A plan of activities was available on notice boards to keep service users informed about the programme of activities. The inspector was informed that a senior carer is responsible for the preparation of the activities programme. On the day of the inspection a Bingo session was arranged for the afternoon. Service users were observed enjoying the game. Some mentioned that they particularly looked forward to the Friday morning party. The inspector was informed that the activities sessions also consisted of external entertainers. From looking at the programme of activities, kindly provided by the proprietor, the inspector noted that outings were not always on the programme and that there were fewer planned activities on Thursdays than on other weekdays and that no activities are arranged over the weekend. The proprietor stated that the GP visits on Thursdays and that service users receive visitors and relatives over the weekend. From looking at the records the inspector noted that two of the four sampled care records contained comprehensive assessment of the recreational and social needs of service users and the other two did not. They all had a plan for Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 14 ‘social isolation’, but without a comprehensive assessment of the needs of service users with regard to this aspect, there is no guarantee that the plan will reflect the needs and interests of the service user. The provider stated that attempts are made by staff to ensure a comprehensive assessment of the social and recreational needs of service users. The home has an open visiting policy. A few visitors were seen in the home. They met service users either in the bedrooms or in the communal areas. Some mentioned that they are able to go for walks in the extensive gardens or to sit in the grounds of the home when the weather is nice. The manager mentioned that visitors could stay for meals with the service users, which were confirmed by visitors. The inspector also observed that visitors were appropriately received in the home and that they were offered beverages during their visits. Lunch was being served when the inspection started. Meals were appropriately presented to service users and most service users enjoyed the meals. Some were observed in the dining room and others had their meals in the lounges or in their bedrooms. Service users mentioned that they are offered choices for the meals and that the home tries to meet their needs as much as possible. Tea with a piece of cake was provided at about 3:30pm. The inspector saw that the kitchen was well equipped and staffed to ensure appropriate and timely provision of food for service users. Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home takes complaints seriously and ensures that the concerns of service users or those of their relatives/friends are listened to and acted upon. EVIDENCE: The home has a complaints procedure which has been in place for a number of years. A poster of the procedure is available on the wall near the manager’s office. The manager also kept records of all complaints and actions taken to resolve the complaints. Service users and visitors said that they meet with the manager when the latter does her rounds and that they would approach her or the proprietor if they had any concerns. All the above demonstrated that the home listens to complaints and takes them seriously. Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19, 24 and 26 The home generally provides a safe and suitable environment for the care of service users. While the home is mainly clean, pleasant and free from unpleasant odours a little input is required to ensure that the home always remains as such. EVIDENCE: The home is found in extensive grounds, which are maintained and accessible to service users. Some service users/visitors mentioned that they like going for walks in the grounds of the home. The home was well maintained and was in an appropriate state of decoration. The main part of the home is the old house and extensions have been added on either sides of the home. There was evidence of ongoing maintenance and redecoration work. The inspector did not see the redecoration and refurbishment programme on this occasion. The bedrooms of service users were in most cases appropriately furnished, personalised and decorated. The inspector observed that service users brought Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 17 their own furniture in the home and other personal possessions. There was a call bell system in place for service users to summon help. The inspector noted that not all the bedrooms’ doors have a lock as per standard 24.5, but noted that those service users who wanted to lock their bedrooms were provided with one. The inspector saw that the flooring (linoleum) in one of the bedrooms was becoming unstuck which could lead to dust and dirt accumulating under the flooring. The registered person must ensure that the flooring/linoleum in all areas are adhered/glued safely to the ground. The home was generally clean but the inspector made some observations. For example he noted that some of the frames for the adjustable beds were dusty and that the television in one of the bedrooms for a service user who was in hospital, was also dusty. He observed that the suction canister for a suction machine had not been emptied while the service user was in hospital for about two weeks. There were also some spillages of gastrostomy feed on the floor, which needed to be cleaned. The inspector noted that the cushion of the chair in another bedroom smelled strongly of urine and that the top of the commode had some faecal stains to it. The registered person must ensure that the above issues are addressed to ensure that appropriate cleaning and infection control procedures are in place in the home at all times. Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The numbers and skills of staff in the home are appropriate to ensure that the needs of service users are met. EVIDENCE: There were 11 carers for the morning shift and 8 carers for the afternoon shift in the old house; and 6 carers in the morning and 4 carers in the afternoon on the new wing; with two trained nurses supervising all the care given to service users. The manager was supernumerary on the day of the inspection, but was attending some training course earlier on. There was evidence of a number of training having been arranged for staff in the home including training in managing aggressive behaviour and dementia. There were carers on NVQ courses and there was evidence of statutory training having been arranged in the home. In addition to care staff there were good numbers of support staff in the kitchen, laundry, for cleaning and for maintenance. The inspector judged that this standard was exceeded. Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38 The manager is clear about her role and about providing leadership to her staff to ensure continuous improvement in the home. The health, safety and welfare of service users are promoted and protected on most occasions. A comprehensive health and safety risk assessment was not available about the use of the corridors to store items such as wheelchairs, laundry skips and bins, which could not only cause obstructions of the corridors (fire exits), but which could also be trip hazards. EVIDENCE: The registered manager has been in post for about three months. Discussion with her showed that she knew the home, the service users and issues within the home. She demonstrated that she has also started to handle some issues such as the training plan and the care records of service users to make them more comprehensive. The manager also showed that she was keen on training and showed the inspector a room that she has developed as a training/resource room in the basement of the home for staff. She stated that Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 20 she has enrolled on the Registered Manager’s Award course, which she would start soon. The inspector observed that there were a number of items, which were kept in the corridors of the home, particularly on the new wing. The corridors were quite wide but there were a number of folded wheelchairs in the corridor, buckets/bins for soiled pads, skips for dirty linen and battery chargers for the hoists lying on the floor with their wires which could be trip hazards. There were also collapsible shelves, which could be used by staff to put things on as necessary. The inspector was aware that the arrangements in the corridors have existed for some time and was sensitive about how to manage the risks with regard to the corridors being fire exits, and being free from clutter/obstacles, which could also be trip hazards. As a result of the above the registered person must ensure that there is a comprehensive health and safety risk assessment regarding the corridors. When the inspector started the inspection he was shown around the home by a staff nurse, who was on the early shift, as he was not familiar with the home. At this stage he noted that the rooms and corridors were being cleaned. The inspector observed that vacuum cleaners and mop buckets were left in the corridors while the cleaners were in the bedrooms or doing other cleaning duties such as wiping things. It is recommended that risk assessments are carried out with regard to leaving cleaning items in the corridors as they could be a trip hazard for service users and staff. The inspector noted that a few wheelchairs had flat tyres, which could pose a problem for those pushing the wheelchairs when service users go out. The manager stated that she was aware of this problem and that she has ordered a number of wheelchairs to replace the old ones. The provider later added that the wheelchairs had labels to show that they were out of commission and were waiting to be collected. While touring the premises the inspector observed that a number of bedrooms doors were kept open by wooden door wedges. The registered person must review the use of doors wedges to keep bedroom doors open and consider other options such as the use of magnetic door holders, within a risk assessment context. Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 4 COMPLAINTS AND PROTECTION 3 x x x x 2 x 2 STAFFING Standard No Score 27 4 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x x x x x x 2 Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 22 NO 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 OP3 Regulation 14(1,2) Requirement The registered person must ensure that all service users have a comprehensive assessment of their needs. The registered person must ensure that all service users have a comprehensive risk assessment for falls. The registered person must ensure that service users or that their relatives are involved in drawing and in reviewing the care plans, with a note made when this is not possible. The registered person must ensure that all service users have a comprehensive continence assessment. The registered person must ensure that all medicines are signed when administered or a code used when the medicines have not been administered. The registered person must ensure that the instructions on medicines labels and those on medicines charts are the same and make the necessary arrangements if they are not the same. The registered person must Timescale for action 30/11/5 2. OP7 13(3,4) 30/11/5 3. OP7 15(1,2) 30/11/5 4. OP8 14(1,2) 30/11/5 5. OP9 13(2) 31/10/5 6. OP9 13(2) 31/10/5 7. OP9 13(2) 31/10/5 Page 23 Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 8. OP9 13(2) 9. OP24 23(2)(b) 10. OP26 23(2)(d) 11. OP38 13(4) 12. OP38 23(4) ensure that medicines for only one service user are administered at a time. The registered person must ensure that all the cupboards containing medicines are kept locked at all times. The registered person must ensure that the flooring/linoleum is glued properly on the ground to prevent the flooring/linoleum from coming up, leading to the possible accumulation of dust and dirt under it. The registered person must ensure that the home is kept to a high standard of cleanliness at all times including addressing the following: that bed frames and all items of furniture are kept free from dust; that the suction canister is cleaned immediately after use; and that spillages of gastrostomy feed are cleaned immediately. The registered person must ensure that there is a comprehensive health and safety risk assessment about using the corridors to store items such as laundry skips, wheelchairs and bins. The registered person must review the use of door wedges to keep bedrooms doors open and consider other options such as the use of magnetic door holders, within a risk assessment context. 31/10/5 31/10/5 30/11/5 30/11/5 30/11/5 13. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 24 No. 1. Refer to Standard OP4 Good Practice Recommendations It is recommended that the provider regularly review the needs of services users who are accommodated on the new wing so as to ensure that their needs can continue to be appropriately met in that location. In particular, consideration should be given to an assessment of the premises and facilities in that part of the home by a suitably qualified person such as an Occupational Therapist, to ensure the suitability of that part of the home with regard to meeting the changing needs of service users. It is recommended that the registered person ensure that there is a record of the pressure relief equipment that is being used for each service user in the care records. It is recommended that photographs or wound mapping of pressure sores are kept at intervals of at least monthly. It is recommended that the practice of placing chair pads on the chairs of service users be reviewed, subject to individual continence assessments and the provision of needs-specific services in agreement with the individual service user/representative. It is recommended that medicines, which are discontinued, are signed and dated by the GP. The registered person should review the programme of activities for service users taking into consideration outings and all days of the week as well as the individual views and needs of service users with regard to activities. It is recommended that risk assessments are carried out with regard to leaving cleaning items in the corridors as they could be a trip hazard for service users and staff. 2. 3. 4. OP8 OP8 OP8 5. 6. OP9 OP12 7. OP38 Kestrel Grove Nursing Home G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlesex 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 G62-G11 S22930 Kestrel Grove V237002 050705 Stage 4.doc Version 1.40 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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