Inspection on 20/04/07 for Kestrel House Lodge Care Home

This inspection was carried out on 20th April 2007.

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 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 House Lodge Care Home 09/05/06

Kestrel House Lodge Care Home 01/12/05

Kestrel House Lodge Care Home 22/08/05

Kestrel House Lodge Care Home 21/03/05

Kestrel House Lodge Care Home 01/03/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Kestrel House Lodge Care Home St Thomas` Avenue Kirkby In Ashfield Nottingham NG17 7DX Lead Inspector Jayne Hilton Key Unannounced Inspection 20th April 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kestrel House Lodge Care Home Address St Thomas` Avenue Kirkby In Ashfield Nottingham NG17 7DX 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) 01623 757 204 01623 750 512 Kestrel.Lodge@fshc.co.uk Keslaw Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Manager post vacant Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The total number of people to be accommodated in the Kestrel Lodge Care Home , St Thomas Avenue, Kirkby in Ashfield, Nottinghamshire, shall not exceed 33 at any one time That the category of service users to be included on the register shall be OP (Old age, not falling within any other category) 33 That within this number, a maximum of 5 service users can be included aged 60 years and over That service users shall not be accommodated in the home unless they come within one or other of the following categories :OP (Old age, not falling within any other category) Aged 60 years and above - restricted to 5 service users Date of last inspection 28th September 2006 Brief Description of the Service: Kestrel House Lodge is a purpose-built home close to Kirkby town centre and is located on a quiet residential avenue. Most of the bedrooms are single, although two doubles are available for those who choose to share. Accommodation is on two floors and there is a passenger lift to the first floor, as well as a staircase for those who are able and prefer to use this. There are pleasant gardens to the rear, which are enclosed, and there are car parking spaces to the front of the property. The home is close to Kirkby town centre and is located on a quiet residential avenue. The weekly fees for the home range between £290-£390. The information about fees was provided by, the acting manager on 18th April 2007. Additional Charges are for hairdressing, Chiropody, Toiletries and Magazines/newspapers. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 6 daytime hours. The main method of inspection used was called ‘case tracking.’ This involves selecting five residents and looking at the quality of the care they receive by talking to them, examining their care files and discussing how support is offered to them by staff members. Many of the people who live at this home have a very limited ability to understand and communicate. Therefore many judgements in this report are from observation and reading residents’ records and documents. Not all residents who were “case tracked” were spoken with, as either they did not wish to give an opinion about the care provided or they were not available. Six residents were spoken with throughout the inspection process however. There were no relatives spoken with at the inspection, attempts were made to contact two people by telephone but they were unavailable Six members of staff, the acting manager and the operations manager were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to residents. This inspection was conducted unannounced. Prior to completing this visit the inspector assessed the homes previous inspection reports, the service history including complaints and adult protection referrals, and a Pre-inspection questionnaire completed by the acting manager. Four completed resident’s satisfaction questionnaires and four relatives questionnaires were also received prior to this inspection. A random Inspection was undertaken of the home on 4th October 2006. A copy of the inspection outcome letter can be obtained on request from The Commission for Social Care Inspection. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home has had a period of instability recently with change and absence of a registered manager, however it was noted that systems were now being organised and staff had clear direction and improved support and development systems in place. Some areas have been redecorated such as the office, some bedrooms and the lounge. The lift is now repaired and fully working. Some medication practices have improved. Work on the fire exit doors and alarms have been approved and are due to commence shortly. Staff have undertaken training in Equality and Diversity. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 7 Protective aprons and gloves are now supplied in proximity of bedrooms and for laundry staff to access as needed. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3,Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their needs assessed prior to admission, are provided with information about the home and a contract upon admission. The home does not provide an intermediate care service. EVIDENCE: All residents are issued with a service user guide, which contains a copy of the complaints procedures and information about accessing inspection reports. Resident’s needs are assessed prior to admission and those people case tracked on the day had contracts in place. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 10 The initial assessment is based on Activities of living identified specific needs such as cultural or religious but this should be expanded further to ensure that any specific diversity needs are captured. Staff have received training in equality and diversity and demonstrated good awareness of respecting the differing needs and values of everyone. The acting manager and staff confirmed there were no residents with any specific diversity needs currently. The home does not provide an intermediate care service. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s health and personal care needs are set out in an individual plan of care, but the system is not consistent and not all of the residents needs were fully assessed in respect of risk or reviewed. The system in place for management of medication does not fully ensure residents safety. Residents do not always feel that they are treated with respect. The management of the home had systems in place for responding to the issues and therefore the judgement made in consideration of this. EVIDENCE: The manager is currently making arrangements for residents and relatives to be involved in the review of care plans and although paperwork was in place none were yet completed. On the whole there is good monitoring of falls, Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 12 mobility, dietary needs, mental health and continence, but this was not consistent for all. One persons care plan file did not contain a completed nutritional assessment and had not been subject to review since October 2006. There was some information omitted from the person’s notes, which was discussed with the manager for clarification. An urgent action requirement was made for the persons care plan to be brought up to date within a week. The management of diabetes was managed well for two out of three people. One persons planning did not contain information about blood sugar monitoring. The acting manager took remedial action during the inspection about this. Another persons care plan contained confusing information about assistance with toileting during the night and in relation to nighttime medication. The acting manager said that she would look into all matters and provide the inspector with an outcome of the findings. It is also recommended that night checks be documented. Healthcare checks were not up to date in all of the files viewed although weights were kept in a separate file and not necessarily transferred to the individuals care plan information. Improved management for healthcare checks is recommended. Risk assessments were mostly in place for manual handling, malnutrition, falls and pressure areas but these had not been completed for a person recently admitted. There was also no evaluation/review of the care plans for this person or any agreement by the resident or their representative. An urgent action requirement was made for this person’s assessment and care plan to be updated within 28 days. Medication was observed to be administered in a satisfactory way but eye drops and liquid medicines were still not being dated upon opening. One person’s medication record indicated medication not taken and coded for ‘other reasons’ however the reason was not recorded on the back of the mars charts. All practices observed on the day and comments from residents and staff confirmed that privacy was respected, however comments made by both residents and relatives indicated that some staff were not always respectful in their manner to people. The comments made were highlighted to the acting manager and operations manager who reported that they would address the matters brought to their attention with urgency. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 13 Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are happy with the activities provided and say they can maintain contact with family and friends and that they are helped to exercise choice and control over their lives. Residents receive a wholesome and balanced diet but not all residents are happy with the food provided. Ongoing development of menus and nutrition is in place. EVIDENCE: Information provided in the pre –inspection documentation demonstrated a good level of activities organised by the activities organiser. Both staff and residents confirmed a good range of activities and outings, which residents say they are satisfied with. Activities provided include bingo quizzes, reminiscence work, 121, crosswords talking reading current affairs, board games, cards, dominoes, entertainers, themed activities. Friendship club, panto trips library and bust trips. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 15 Residents confirmed they could receive visitors at any reasonable time and in private. Care plans contain information about individual preferences and residents and staff confirmed that people could make decisions about their daily lifestyles such as when to get up, retire to bed, participate in activities etc. Residents are offered three full meals a day with hot and cold drinks and snacks available and offered regularly. One resident needs a soft diet and diabetic diets are catered for. The menu is varied and appears nutritious but residents spoken with and comments made in the returned questionnaires said that although they are offered a choice the food was poor or commented that the meals are’ eatable’, “they give us too big portions and there’s a lot of waste”. The acting manager reported that she had recently undertaken a survey with residents about food and that grapefruit and prunes had been introduced as a result. The acting manager said that she intended reviewing the menus. Mealtimes were observed to be unhurried and staff assisted residents discreetly and sensitively. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are informed how they can make a complaint should they not be happy and say they feel listened to. Residents are protected from abuse. EVIDENCE: The acting manager provided information that five complaints had been made to the home in the previous twelve-month period and three of those were upheld. Records were viewed at the inspection, which demonstrated that complaints hade been responded to and dealt with promptly and adequately. Complaints made were in relation to the lift being broken. Missing dentures and personal care and dignity issues. One complaint was currently being investigated by the home. Despite the complaints procedures being clearly displayed in the home, not all residents said they knew how to make a complaint should they have anything they are not happy about. It is recommended that all residents be issued with an easy read version of the complaints procedures and sign that they have been issued with a copy. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 17 Staff are trained in Protection of Vulnerable adults and those spoken with discussed what they would do should they be aware of poor practice and what constitutes abuse. The whistle blowing policy is displayed and staff knew its contents. The acting manager was aware of the Safeguarding Adults protocols and reported that she would be obtaining further training for herself and staff in the topic. There have been no safeguarding adults issues since the previous inspection. Residents spoken with said they felt safe. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, comfortable and clean home. EVIDENCE: The home was comfortable, clean and smelled fresh. Many rooms have been decorated and some new carpets fitted to resident bedrooms. Bedrooms are personalised well equipped and safe. Suitable equipment and adaptations are provided throughout. Residents can spend time in the garden, which is accessible and maintained. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 19 The laundry facilities were satisfactory and gloves, aprons, liquid soaps and paper towels were in adequate supply throughout the home and staff observed to be wearing them. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported and protected by the homes recruitment policy but the registered person must ensure that all staff files contain the documentation required by regulation. Staff are trained to do their jobs but further training should be provided in NVQ’s , diabetes, code of conduct and policies for taking breaks to ensure all residents needs are fully met. EVIDENCE: Four care staff were on duty on the day of the inspections and rotas for 23 residents viewed as adequate. Rotas are reviewed according to the dependency levels of residents. Two staff currently cover 7.30pm to 7.30am. Housekeeping , catering, handyperson and laundry hours are provided in addition. The acting manager reported that 11.7 of care staff have achieved NVQ level 2 or above. The home needs to work towards achieving at least 50 of staff trained at this level to meet the standard. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 21 Staff confirmed they had been given a copy of the General Social Care Councils Code of Conduct recently. Housekeeping, catering, handyperson and laundry hours are provided in addition. Comments were made by relatives in relation to staff on duty taking their breaks at the same time. Staff were observed taking their break together, which is not good practice. The issue was raised with the acting manager and operations manager who reported that the staff actions went against company policy and the matter would be dealt with. Four staff files were examined and overall these evidenced good recruitment practices, however not all files contained a photograph as required by regulation and therefore the requirement set at the previous inspection is outstanding. The acting manager reported that staff had been requested to bring in the relevant documentation and that the matter would be dealt with as priority. Training records were viewed and the acting manager was updating the training matrix from the staff files and other records. Staff members spoken with confirmed training in, fire safety, first aid, food hygiene, Protection of Vulnerable Adults, care `planning, medication management and induction. Health and safety training is overdue as is infection control. The acting manager was arranging this training partly in house and with an outside agency. The Provider has stated that the training must be achieved within twelve weeks. It is recommended that staff undertake training in diabetes care and refresher training arranged around comments made by relatives and residents about staff conduct. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home, which is run and managed in their best interests and protects their health and safety. EVIDENCE: The acting manager is newly appointed and is preparing to make an application for registration with CSCI. She is a qualified Registered Mental Health Nurse with management qualifications. She reported that she would also be undertaking the Registered Managers award. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 23 The home has had a period of instability recently with change and absence of a registered manager, however it was noted that systems were now being organised and staff had clear direction and improved support and development systems in place. Staff supervision had lapsed over the last year but this was now being recovered. The registered provider/organisation has several quality monitoring systems and audits in place. Residents/relatives meetings are held and minutes kept. A sample of resident’s financial records were examined and found to be satisfactory. A sample of Health and Safety records were viewed such as Annual Gas safety, fire risk assessment, and Portable Appliance testing and water outlet tests, all were satisfactory. In the kitchen food safety management systems are in place but care is needed to ensure all opened foods are date labelled upon opening and that cereal containers are kept clean. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The Registered Person must ensure that care plans are kept reviewed and up to date and that appropriate consultation with service users are part of the process. Previous timescale 28/11/06 Not Met 1. You are required to ensure that the care plans for the identified resident contains up to date information and is appropriately reviewed. You are required to make the residents care plan available to the resident. This will ensure the resident’s needs are fully met. Urgent Action required. 2 OP8 13,14 2. You are required to ensure that risk assessments in relation pressure areas, nutritional needs, social isolation and disability needs for the identified resident contains up to DS0000008705.V334347.R01.S.doc Timescale for action 27/04/07 18/05/07 Kestrel House Lodge Care Home Version 5.2 Page 26 date information and is appropriately reviewed. You are required to make the residents care plan available to the resident. This will ensure the resident’s needs are fully met. 3. OP9 13 Urgent action required. The Registered Person must ensure that liquid medicines and eye drops are dated on opening. Previous timescale set 28/11/06 Not Met. This will ensure residents medication is stored and administered to them safely 4. OP29 7,9,19 The Registered Person must ensure that staff personal files contain the documentation required by regulation [Schedule 2 and 4] Previous timescale set 28/11/06 Not Met. This will ensure residents are fully safeguarded. 20/06/07 20/06/07 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 Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 27 1 2 3 4 5 6 7 8 9 10 11 OP3 OP8 OP8 OP9 OP9 OP9 OP10 OP28 OP30 OP38 OP38 Expand the section in the assessment information to embrace equality and diversity needs of individuals. Implement night checks, which are fully documented and address the issue re night time assistance with toileting. Care plans should be in place for the management of healthcare checks such as chiropody, dentist and optician and hearing checks etc Investigate the Issue of confusion re medication discussed at the inspection and inform the CSCI of the outcome. Where ‘other’ is indicated as the reason of medication not given, the reason should be documented on the back of the medication administration record. Ensure all handwritten entries on the medication administration record have two signatures Address the staff conduct areas discussed. Seek to achieve 50 of staff trained in NVQ 2 or above. Provide training for staff in diabetes Date label all opened food items with use by dates. Ensure cereal containers are kept clean. Kestrel House Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Lodge Care Home DS0000008705.V334347.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!