Inspection on 20/03/07 for Kestrel House

This inspection was carried out on 20th March 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kestrel House 22/03/06

Kestrel House 13/12/05

Kestrel House 09/12/04

Kestrel House 21/06/04

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

CARE HOME ADULTS 18-65 Kestrel House 75 Harold Road Leytonstone London E11 4QX Lead Inspector Sandra Jacobs-Walls Unannounced Inspection 20th March 2007 10:00 Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 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 House DS0000007223.V330983.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 Adults 18-65. 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 House DS0000007223.V330983.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kestrel House Address 75 Harold Road Leytonstone London E11 4QX 020 8556 4037 0208 558 2761 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) Shanti Healthcare Limited Mr Neraindas Nunkoo Mr Neraindas Nunkoo Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One (1) place for a service user over the age of 65 can be accommodated. 22nd March 2006 Date of last inspection Brief Description of the Service: Kestrel House is a care home, which offers personal care and support to younger adults who have mental health support needs. Kestrel House is a large semi-detached house situated in a quiet residential area of Leytonstone. It is privately owned and operated and the registered manager is one of the registered providers. The home is close to local shops and other community facilities and there are good links to public transport. Whilst there is one double room only one service user occupies it. All but one bedroom has en-suite facilities and are situated on the ground and first floor. Communal space and appropriate bathroom and toilet facilities are available. There is a passenger lift to the first floor. There is a large garden available for the use of service users. At the time of the inspection, there were 14 service users living at the home. Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection of Kestrel House took place on 20th March 2007 for the duration of seven hours. Assisting the inspection was the home’s deputy manager. The purpose of the inspection was to assess the home against key National Minimum Standards and to gauge the service’s success at addressing outstanding requirements made at the last inspection, which was conducted in March 2006. The inspection process included the interview of four service users and two members of staff, the review of three service users individual case files, the review of key policies and procedures and an accompanied tour of the home’s premises led by one of the service users. As a result of the inspection 17 requirements and no recommendations were made. The inspector would like to thank all service users and staff who co-operated and contributed to the inspection. What the service does well: The inspector was introduced to many of the service users currently living at Kestrel House and had the opportunity to interview in private, four service users. All four service users indicated positively that they felt well looked after and had good relationships with all staff members. Each service user indicated that they were happy with the home’s general environment and facilities and were particularly pleased with their private bedroom and meals provided by the home. One service users said; “It’s pretty good here - the staff have helped me a lot, I came straight from hospital and they’ve helped me move on. I really enjoy it here” Another service user commented; “The home is alright – my bedroom is comfortable and the kitchen and lounges suit me”. One other service user interviewed commented; “The staff here are pretty good, they look after you and help you out. The best thing about living here is that you get to come and go as you please – I like that.” Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 6 The inspector observed during the inspection that staff was attentive to the needs of service users and that the relationship between staff and service users were good. The review of three service users case files confirmed that staff were provided with comprehensive information about the needs of service users and how best to meet these needs sensitively and in accordance with the wishes of residents. What has improved since the last inspection? What they could do better: Despite noted success in addressing outstanding requirements, the inspection highlighted a number of new issues, some in need of urgent resolution. The home must ensure that MAR charts are accurately completed in every instance, the home’s adult protection policies and procedures are in need of urgent revision and the complaints procedure must be amended. Monthlyunannounced monitoring visits must commence and as a matter of priority, the home must address excessive smoke in all communal areas caused by habitual smoking of cigarettes by service users. The home’s environment is in need of further improvement; worn and stained carpeting in communal areas must be replaced, fire doors must be kept shut, the first floor bathroom tiles must be replaced, and net curtains must be placed around the home to ensure service users’ privacy. Windows must be kept clean and patchy paintwork noted in communal areas must be re-painted. All service user files must evidenced completed and current care plans and Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 7 staff personnel files must evidence all information as outlined in Schedule 2 of the Care Homes Regulations. 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 House DS0000007223.V330983.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): No new service users had been admitted to the home since the last inspection, therefore no standards under this heading were assessed on this occasion. EVIDENCE: Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All service users who met with the inspector indicated that they had fair knowledge of their placement goals. The inspector reviewed the individual case files for three service users and was encouraged to note that comprehensive background and current information was maintained on file. Two files reviewed contained very detailed care planning documents, comprehensive risk and nutritional assessments and evidence to suggest that the home was liaising effectively with external professionals such as CPN.s the mental health locality worker, consultant psychiatrists etc. The inspector did note however that for one file seen, care plan documentation was incomplete and gave no indication of progress made in addressing placement goals. The deputy manager assisting with the inspection could give no explanation as to why this was the case. All care plans must be kept current and document outcomes of placement goals. Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 11 Service users who spoke with the inspector indicated that they felt that they participated well in the decision making process. Many commented that they had freedom of movement i.e. could go wherever they wanted, made choices with regard to meals they wished to eat, choice of support from staff or not etc. In addition, the home’s deputy manager commented that the service operated ‘an open door policy’ where service users were free to voice their opinions with any member of staff whenever they wished. The inspector observed this practice as service users freely approached the staff office for discussion with the deputy. Service users had also been encouraged to make decisions with regard to bedroom décor and furniture. The service had developed a new key work system for individual service users so that each had a designated staff member to work with them. It was hoped that this would facilitate greater decision-making by service users. In an attempt to further solicit service users opinions, all service users had access to independent advocacy services, the format of residents meetings had been altered to be more service user led and a suggestion box was available for service users to make comment on any area they wished. In reviewing three service users files, the inspector was satisfied that comprehensive risk assessments were in place, documented in most cases by the referring agency and the staff of the home itself. Risk assessments seen were detailed and relevant to individual service users. Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 &17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users who met with the inspector indicated that they felt they were engaged in appropriate activities while living at the home. The deputy manager commented that due to the wide age range of service users resident at Kestrel House, staff was careful to offer appropriate activities to individuals. So, for example, some of the younger service users participated in a Tai Chi course, while others service users enjoyed quiz nights, going to the local café, playing bingo and watching selected DVD’s. The inspector was also informed that the service had recently hired a qualified art teacher to lead art classes in the home. Some service users participated in volunteer work whilst all had enjoyed a long weekend break to Brighton last year. The home’s deputy commented that that service users responded more positively to outings during the summer months and so service users were more likely to go for Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 13 walks to the local reservoir, cinema and shopping trips when the weather was pleasant. Service users made good use of the local community, primarily for shopping, places of worship, to attend local college courses, the library and other community events. Some service users were members of the local leisure centre. Service users who spoke with the inspector indicated that they had frequent visitors to the home and enjoyed visiting friends and family on a regular basis. One service user told the inspector that he was visited my his mother twice weekly at Kestrel House, and he visited the family home every Saturday, while another service user shared that her daughter made infrequent visits to see her at home. The deputy manager commented that visits from family and friends of service users were actively encouraged, while staff carefully monitored visits from unknown individuals. Some service users had identified partners who also visited. Service users and staff interviewed indicated that they felt service users rights were very much respected and their responsibilities well recognised. Independent advocates were easily accessed and service users were encouraged to maintain their autonomy and participate in the decision making process. With regards to meals provided, most service users were very satisfied with the choice of meals offered. The home employed two cooks and the review of the home’s four weekly rotating menu confirmed that meal choices were extensive, catering for those who ate meat and vegetarians, those with a diabetic condition and those needed a low or high caloric intake. One service users commented that while he agreed that meals offered were generally very good, that he felt that his preferred (culturally appropriate) meal should feature more regularly. The inspector reviewed the home’s menu planner and felt that there was a case to be made as the specified meal choice made by the service users appeared only twice in a four week cycle. The home must ensure that indicated meals preferences are offered to service users on a regular basis. Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The deputy manager commented that where necessary and in accordance with care plan goals, service users received personal care services. Staff received guidance around setting tasks, how to approach service users sensitively and to ensure appropriate level of staff input was provided. The deputy indicated that various levels of support/ supervision was needed to meet the individual needs of service users and thus for the service user who was visually impaired, the level of personal care support was higher than others. The inspector asked service users whether they felt they were appropriately supported by staff in managing personal care tasks. Most service users asked responded that they felt staff supported them appropriately, however one service user told the inspector that she did not understand why staff continued to assist her with bathing and washing her hair, as she felt more than able to complete these tasks herself. This matter was brought to the attention of the deputy manager, who agreed to review personal care tasks assigned to staff Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 15 for the service user. Staff must ensure that service users are proactively encouraged to complete personal care tasks where service users have the ability to do so. Service users who met with the inspector indicated that they felt their physical and emotional health needs were very well met. Service user files reviewed by the inspector evidenced comprehensive information about the physical and in particular the mental health support needs of service users. So, for example files contained good documentation about individual service users’ medical and mental health diagnosis and how these were to be addressed by staff of the home and other professionals. The inspector noted that almost all service users had been prescribed medication. The inspector reviewed the home’s written medication policies, which were considered satisfactory. The inspector also reviewed in detail the medication information for one service user. While information was clear and consistent, the inspector noted via MAR sheets two omission of staff signatures, one on the day of the inspection and one other, the night before. The deputy explained that he had been responsible for the signature omission seen for the day of the inspection, but did not have an explanation for the other omission noted. He commented that is was probable that the medication had been given the night before as prescribed, as the dose was no longer in the assigned dosset box. The deputy explained that staff had recently participated in medication training facilitated by the local pharmacist and that there were mechanisms in place at the end of every shift, to monitor the correct administration of service user medication and avoid medication error. He acknowledged that despite these safeguards, an error had occurred. Staff must ensure the accurate documentation on MAR sheets in accordance with safe practices and the home’s medication policies. Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users who spoke with the inspector indicated that generally they were very happy with services provided and had no cause to make any complaints. Some service users seemed unsure about how the home’s complaints procedure worked. The inspector reviewed both the home’s written complaints procedure and information available to service users via the home’s Service User Guide about making complaints. The inspector noted that the written complaints policy and service user guide did not highlight the local authority as a source to make complaints. The policy also did not identify to whom service users could make complaints against the manager; the inspector felt it important that senior member of the organisation be identified to explore/investigate any such complaints. Both the Service User Guide and formal complaints policy needed to include the full and correct contact details of the local CSCI office for service users and/or their advocates to contact if necessary. The inspector reviewed the home’s record of complaints made since the last inspection, of which there were two. The inspector was satisfied that these complaints had been appropriately resolved and were in accordance with the home’s complaints procedures. The deputy manager informed the inspector that there had been no incidents of an adult protection nature since the last inspection. Review of the home’s Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 17 incidents book confirmed that there were no records of any abuse type incident having occurred in the home over the past 12 months. The inspector then reviewed the home’s adult protection policy and was concerned for its contents. The written policy offered guidance to staff about the management of abuse type incidents that may occur in the home, which was not in line with accepted safeguarding protocols. The policy inaccurately advised, (amongst other issues) that managers of the home could initiate and conduct adult protection investigations without the knowledge of the placing authority. This is very dangerous practice and not in accordance with safe adult protection procedures. The home must as a matter of priority obtain and maintain on site a copy of the local authority’s adult protection policy and procedures. The service must also, as a matter of urgency, revise and amend its existing adult protection policies to ensure that procedures and practice is in accordance with local authority adult protection protocols. Staff must then receive appropriate training focused on the revised policies and practices. Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,28 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection, the inspector participated in a tour of the home’s premises that was led by one of the home’s current service users. The inspector saw all communal areas and the bedroom of the service user facilitating the tour. Other service users had commented when asked that they were generally happy with the home’s environment and their bedrooms in particular. The deputy manager explained that a number of environmental issues were being addressed by the service, so for example much of the home’s carpeting had been replaced; there were plans to further expand the premises to include an increase in service user beds and a new conservatory. Two new washing machines had been purchased recently and the home’s bathrooms were due to be re-decorated. Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 19 During the tour of the home, the inspector was stuck immediately by the impact of cigarette smoke in all communal areas of the home. At the time of the inspection all 14 service users were active smokers. The service’s smoking policy was reviewed and while the written documents acknowledged the need to safeguard service users and staff from the effect of ‘passive smoking’, little action had been taken to prevent these effects. Staff had highlighted this as a cause for significant concern. The deputy manager commented that in the home had planned to expand its premises, including the building of a conservatory that will become the designated smoking area in the building. At the time of the inspection however, smokers could use both lounges, dining areas and the garden to smoke. The home must as a matter of urgency take measures to reduce the effects of cigarette smoke inhalation and strategically install extractor fans in areas used for smoking. The inspector observed during the tour of the home’s premises that a number of fire doors including the door to the kitchen area remained propped open. This is not conducive to safe fire practices and posed unnecessary risks to service users and staff. All fire doors must remain closed. The inspector reviewed the home’s record of conducted fire drills and noted that while the date was well documented no times were recorded. It was therefore difficult to gauge at time of the day the fire drill had been held. The deputy manager indicated that most of the home’s fire drills were held at times when most of the staff group were on the premises. It was the inspector’s view that this practice defeated the object on monitoring the evacuation of the building at times when fire drills were not expected – in this case it seemed relatively easy to gauge when the fire drill might occur. The registered manager must ensure that the time fire drills are held was recorded and fire drills were conducted at varying times of the day and with varying numbers of staff on the premises. The inspector also observed the following; • • • • The bath tiles on the bath of the first floor bathroom had been removed and needed replacement The refrigerator in the first floor dining area needed cleaning and the icebox defrosted. Patchy and discoloured paintwork seen in communal areas of the home, accessed by smokers needed to be repainted. Many of the windows of the home needed cleaning and those that looked out into the street did not have net curtains. This resulted in passers-by having view of activities inside the home when heavy curtains were not drawn. This is not conducive to respecting the privacy of service users; net curtains for around the home must be purchased and erected. Carpeting to the lounge areas used by smokers were worn and discoloured and in need of replacing. DS0000007223.V330983.R01.S.doc Version 5.2 Page 20 • Kestrel House These issues must be satisfactorily addressed if the home is to meet National Minimum Standards that relate to the home’s environment. Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both service users and staff interviewed indicated that they felt the staff team worked well with service users to encourage positive outcomes. The deputy manager said he was satisfied with staff performances and commented that many of the staff group had recently participated in a series of training facilitated by a training consortium. Training had included POVA training, food hygiene, health and safety first aid, fire training and risk assessments. The previous inspection had highlighted the need for the service to ensure that the staff group had achieved minimum NVQ training requirements. The deputy offered documented evidence that confirmed that together with newly recruited staff, over 50 of the staff group had completed or had embarked on relevant NVQ training Of the 20 staff employed at the home, eight had completed NVQ training at level 2, one had completed NVQ training at level 3, the registered manager had completed the Registered Manager’s Award and NVQ training at level 4. Two other staff members were in the process of completing NVQ 2 training, Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 22 while the remaining staff was awaiting enrolment onto NVQ training programmes. The inspector reviewed the personnel files for six members of staff. Most files seen contained all staff information as outlined in the regulations, however, the inspector noted that three of the CRB disclosure forms had applied for by agency’s other than Kestrel House. The deputy manager acknowledged that CRB disclosures are not ‘portable’ and that all staff must have CRB disclosures that are countersigned by a senior member of the organisation. The inspector also noted that one staff member’s file did not contain positive proof of identification. The registered manager must ensure that all staff personnel files contain full information as outlined in Schedule 2 of the Care Homes Regulations. Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users who spoke with the inspector indicated that felt they were well looked after and that the home was well run. The deputy manager shared with the inspector that the home’s current registered manager had resigned from his post and his departure was imminent. It was anticipated that his replacement would likely emerge from the home’s current staff group. The inspector explained the necessary registration process that needed to be complied with. The inspector was generally satisfied that outcomes for service users were very positive, however, attention needs to be paid to the recruitment of staff, the development and implementation of robust adult protection policies and the Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 24 home’s environment if service users are to benefit from a service that can demonstrate high quality care and ensure the health, safety and wellbeing of service users. The previous inspection had highlighted the need for the home to develop and improve upon its quality assurance systems. During the inspection, the deputy manager shared with the inspector new mechanism in place to assist with quality assurance. These included the development of key working as system to better monitor the individual needs of service users and the development of the routine distribution of satisfaction survey’s for stakeholders. It was anticipated that periodically, an overview of general service provision and delivery would be undertaken by the organisation. Residents meetings would continue to be held periodically. The inspector commented that in addition to these measures, the service must introduce self-monitoring visits as per regulation 26 of the Care Homes Regulations. It was the inspector’s view that unannounced monitoring visits and subsequent reports would enhance the home’s ability to identify weaknesses and offer resolution. Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 2 X X 2 X Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 Requirement The registered manager must ensure that all service users care plans document progress in achieving placement goals are kept current. The registered manager must ensure that indicated service user meals preferences are offered to service users on a regular basis. The registered manager must ensure that service users are proactively encouraged to complete personal care tasks where service users have the ability to do so. The registered manager must ensure staff document accurately on MAR sheets the administration of service users medication. The registered manager must ensure that the home’s complaints policy include the contact details of both the local authority and the local CSCI office and details of whom service users/advocates should approach in the event of a complaint being made against DS0000007223.V330983.R01.S.doc Timescale for action 01/06/07 2. YA17 16(2)(i) 01/06/07 3. YA18 12(2) 01/06/07 4. YA20 13(2) 01/05/07 5. YA22 22 01/06/07 Kestrel House Version 5.2 Page 27 the home’s registered manager. The home’s Service User Guide must be amended to include the contact details of the local CSCI and local authority offices in information given about making complaints. The registered manager must ensure that the home keep on site a copy of the local authority’s adult protection procedures. The registered manager must ensure that the home’s adult protection policies and procedures are revised in accordance with those of the local authority The registered person must ensure that staff receive appropriate training in the use of newly revised adult protection procedures The registered manager must ensure that extractor fans are strategically installed in areas of the home that are used for smoking. The registered manager must ensure that all fire doors of the home remain closed. The registered manager must ensure that the time fire drills are held was recorded and fire drills were conducted at varying times of the day and with varying numbers of staff on the premises. The registered manager must ensure that missing bath tiles to the first floor bath are replaced. The registered manager must ensure that the first floor refrigerator is kept clean and that the icebox is defrosted. The registered manager must ensure that net curtains are DS0000007223.V330983.R01.S.doc 6. YA23 13(6) 01/05/07 7. YA23 13(6) 01/05/07 8. YA23 13(6) 31/05/07 9. YA24 23(2)(p) 01/08/07 10 11. YA24 YA24 23(4)(a) 23(4)(c) 01/05/07 01/06/07 12. 13. YA27 YA30 23(2)(d) 16(2)(j) 01/06/07 01/05/07 14. YA24 12(4)(a) 01/05/07 Page 28 Kestrel House Version 5.2 15 YA24 16(2)(c) 16 YA34 19 17. YA39 26 purchased and erected in the windows of communal areas to enhance the privacy of service users. The registered manager must ensure that worn and discoloured carpeting to the home’s lounge areas are replaced. The registered manager must ensure that all staff personnel files contain full information as outlined in Schedule 2 of the Care Homes Regulations. The registered manager must introduce and implement selfmonitoring visits as per regulation 26 of the Care Homes Regulations. Subsequent reports must be forwarded to CSCI. 01/06/07 01/06/07 01/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kestrel House DS0000007223.V330983.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 House DS0000007223.V330983.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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