Inspection on 17/08/06 for Kiln Court

This inspection was carried out on 17th August 2006.

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

Kiln Court 29/06/07

Kiln Court 08/11/05

Kiln Court 26/04/05

Kiln Court 12/10/04

Kiln Court 19/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Kiln Court Lower Road Faversham Kent ME13 7NY Lead Inspector Sue McGrath Key Unannounced Inspection 09:45 17th and 21st August 2006 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 Kiln Court DS0000037750.V302308.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. Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kiln Court Address Lower Road Faversham Kent ME13 7NY 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) 01795 532183 01795 530942 Kent County Council Mr Michael Philip Roberts Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (29), Physical disability (1) of places Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD is restricted to one (1) person with a PD (frail elderly) whose d.o.b. is 16.01.1945 8th November 2005 Date of last inspection Brief Description of the Service: Kiln Court is situated in the village of Ospringe, Faversham. Kiln Court is owned and run by the local authority, Kent County Council and supports older people over 65 years and one person between 55 and 65 years of age for long term, short term and respite care. The Home has one storey with level access throughout the building. There are 30 single bedrooms with wash hand basins and a call bell system fitted. Two bedrooms are available with en suite facilities suitable for people who may use a wheelchair. The Home has a number of lounges and dining rooms. A Registered Manager, Deputy Manager, Senior Team Leader, Team Leaders, Care Staff, Maintenance man, Administration assistant, Cook and Domestic staff, are employed at the Home. The Home provides 2 waking night staff from 9pm to 7am.The Home has pleasant grounds and garden and is within walking distance of local shops and bus stops. There is a day centre as part of the Kiln Court site. Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Sue McGrath carried out this Key Unannounced Inspection on the 17th and 21st August 2006. The Inspection consisted of discussions with the Acting Manager, Pam Lloyd, the Deputy Manager, Team Leaders, the Pre Inspection Questionnaire, 3 Relative Comment cards, 5 Service User Comment cards, meeting with 4 staff, some relatives and many Residents. Time was also spent looking through staff files, Service User plans and other paperwork. A discussion also took place with the resident Occupational Therapist. The home was split into 3 units, Ospringe, Abbey and Davington. These were spacious and in average decorative order and free from any odour. The staff and residents were very welcoming. The majority of the service users stated they were very happy to live at Kiln Court and all said they felt well looked after. Good rapport was seen between staff and residents. One concern raised by several of the service users was the high number of agency staff used in the home. Discussion with the Acting Manager indicated that staff recruitment was underway and this issue should improve soon. All of the residents said the food was very good and a choice was given. A requirement made at the last inspection regarding regular supervision had not been fully implemented and will remain in place. Some details on staff files were not complete so the requirement made at the last inspection regarding this will remain in place. Fees for the home are a maximum of £351.91 The Inspector left the home with no major cause for the concern for the Residents health, safety or welfare. The overall quality of this service is good. This judgement has been made from the evidence gathered both before and during this visit. What the service does well: Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 6 The service provides a homely and caring service in which to live and has a dedicated and professional staff group. No Service User attends any Doctors, Dentist or Hospital appointment on their own if family are not able to attend, unless they choose to do so. The quality of food is good, healthy and varied. The homes Recuperative Care group was very responsive to admissions and needs and has achieved excellent outcomes. Service users in this wing were especially pleased that they had been given a chance to return home where possible. Some said their progress had amazed them. What has improved since the last inspection? What they could do better: Care planning is in urgent need of review as the plans seen contained insufficient information and guidance to ensure service users needs were fully met. Permanent staff were aware of the needs of the service users through experience in working with them, but the high number of agency staff used means they may not be aware of their needs of individuals. Life for the service users could be enhanced if some of the environment was improved and a planned maintenance and renewal of fabric needs to be introduced and adhered to. Radiator covers in the corridors are required. Some areas of infection control could be improved. Supervision needs to be improved and monitored on a regular basis. Some details in the staff files need to be confirmed and recorded. It would be helpful to the Manager to have a current training matrix so that future training needs can be managed. Quality assurance could be improved. A more structured approach to producing an Annual Development plan should be taken. Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 7 A permanent Registered Manager needs to be appointed. 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. Kiln Court DS0000037750.V302308.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 Kiln Court DS0000037750.V302308.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-6 Service users and families are provided with detailed information on Kiln Court, which enables them to make an informed choice about the home. Prospective residents are fully assessed prior to moving into the home to ensure assessed needs can be met. Prospective service users benefit from having trial visits so they can ensure that the home will be suitable for them. Service users using the recuperative care service are helped to maximise their independence and return home. EVIDENCE: Evidence was seen that the home has a Statement of Purpose and a Service User Guide in place that assists prospective service user in making choices about the home. Discussion with service users who were admitted on shortterm care confirmed that they were assessed prior to admission by the home. Records also confirmed that in depth assessments do take place and the home will only admit service users whose needs they can meet. Some discussion with the Acting Manager highlighted concerns that she was not always consulted on the care needs of new service uses in the Recuperative Care wing. This had previously caused some problems and some inappropriate Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 10 clients were admitted. However the method of assessment had now improved and this issue was now not a major concern. The Registered Manager is reminded that it is his responsibility to ensure that all assessed needs can be met by the home. Residents and families confirmed that they were encouraged to visit the home prior to admission and that they were involved in the process. A written contract was signed and a copy put on the residents file. Discussion with several residents on the recuperative care wing indicated that they were very happy with the service offered. Evidence provided by the Occupational Therapist confirmed that the service is having excellent outcomes. The figures for April to July 2006 confirm that 25 of service users were discharged home either independent or with family support with 50 returning home with support from social care services. Only 4 were admitted to residential care homes. 14 returned to Hospital and 7 were in temporary placements awaiting permanent outcomes. The predicted alternative if recuperative care had not been available was that 15 would have been admitted to hospital, 5 would have created a delay in discharge from hospital and 30 would have been admitted to a residential setting. The average age of people using the service was 83 years old, with the oldest being 98 years of age. Of the eight units offering recuperative care within social services, Kiln Court has the highest percentage of service users to return home. This service appears to be successful due to the close working of the home and the health authority staff. There is clearly a need for the service to continue. Kiln Court DS0000037750.V302308.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 Individual care plans urgently need reviewing. Health needs are met and service users benefit from having full access to all professional health care services as required. Service users are protected by the home’s policies and procedures for dealing with medicines. Service users are treated with respect and can be assured the home will handle the issue of illness and ageing sensitively. EVIDENCE: The CERRUS programme that allows for care planning, risks assessments and recording of information mentioned in the last report is not going to become operational. The home does have new care plans and the Acting Manager had recently introduced these in the home. A high number of new care plans were viewed and it was very disappointing to find they were not fully operational. It would appear that staff had received little training in the completion and use of these new care plans and there appeared to be some confusion as to who filled in all of the relevant sections. This meant that few risk assessments had been Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 12 completed. Some of the Manual Handling assessments were incorrect or simply not filled in. Little evidence could be found of any social interests or life plans. This was discussed with the Acting Manager who agreed that the plans were mainly incomplete and not effective. One other area of concern was the diabetic care offered. The last report indicated that protocols for the care of diabetes had been written and put on file, however these were not in place in care plans and little evidence could be found of any appropriate risk assessments or safe method of working. The protocol was later given to the Inspector. This needs to be a working document. A risk assessment for one service user who wished to self medicate could not be found. This needs to be included in the care plans. A requirement will be made to ensure the system for care planning is urgently reviewed and the Acting Manager is advised to monitor care plans on a regular basis to ensure full compliance. The administration of medication was assessed and found to mainly conform to the guidelines issued by the Royal Pharmaceutical Society of Great Britain. The one area that needs to improve is the risk assessments of service users who self-administer their own medication. These were not evident in the care plans. All of the permanent service users were registered with a local Doctor. The short-term and Recuperative Care service users, if they were local, kept their own Doctor. If not local they were temporarily registered with Dr Kesson. The home confirmed a good working relationship with local G.P.s. All service users had full access to other health professional according to need. Many service users were spoken with and all said how kind the staff were and how well they were looked after. Comments like ‘I have a really good rapport with staff’ and ‘staff look after me very well’ were made. One service user said that prior to coming to Kiln Court she had been very nervous and did not really want to come in, but since she had settled in she now thought it was the best move she could have made. Another service user stated that staff were very respectful especially at bath times. The main complaint from the service users was the high number of agency staff used. And comments like ‘I like to know the person who is given me personal care’ and ‘I am not looked after as well by some of the agency staff’ were made. The home does need to react to these comments and act appropriately if agency staff are causing residents some concerns. The issue of caring for terminally ill service users was discussed and the Inspector was satisfied that staff would treat service users and their families with care, sensitivity and respect at all times. Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. Dedicated activity coordinators would improve the social life of service users. The service users benefit from the appetising meals and balanced diet offered by the home and those service users requiring specialist diets are well catered for. EVIDENCE: Several of the service users spoken with confirmed that they were very happy at Kiln Court and that they enjoyed the lifestyle offered however some said they were bored and would like some more organised activities. When asked about activities in the Day Centre several said that they could attend but often it was difficult to get there or sometimes the activities were not of their choice. One lady said that she does like to play bingo but with her failing eyesight it was too difficult for her now. Not all residents want to participate in organised activities and some prefer to remain quiet in their lounges. A solution might be to have some dedicated activities staff in the residential unit. Several service users said it would be nice just to have someone to sit and chat to or to just spend some time alone on a one to one basis. Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 14 Service users were seen to be encouraged to participate in making choices in their lives and taking responsibility wherever possible for washing and dressing. Meals were provided through a central kitchen and were taken to the units on a heated food trolley. All of the service users spoken with said the food was always very good and there was always plenty of it. The menus were varied and offered a good choice. Staff and service users confirmed that a choice was always given at each mealtime. Service users said that they were offered plenty of drinks and could ask for extra drinks if they wanted more. Discussion with the cook confirmed that specialist diets could be catered for. Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 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 the following standard(s): 16-18 Residents are protected by a robust complaints system and service users and relatives feel their views are listened to and acted upon. Service users legal rights are protected. The home has robust adult protection policies and procedures to ensure that residents are protected from abuse. EVIDENCE: The requirement made at the last inspection regarding the investigation and recording of complaints had been met. According to the records offered to the inspector the home had received six complaints in the last year. Five had been substantiated with one partially substantiated. All had been responded to appropriately and with in the agreed timescales. Several visitors were spoken with and all were aware of the complaints procedure and felt confident that their concerns would be swiftly dealt with. Service users also confirmed that they would know how and who to complain to. The home arranged postal voting for any service user who wished to partake in the political process enabling them to vote in elections. Kent County Council had robust procedures in place to ensure that service users were protected from all forms of abuse and staff spoken with were Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 16 familiar with the policies. The majority of staff had attended training in Adult Protection. Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Residents benefit from living in a clean, safe, adequately maintained environment and have safe access to comfortable indoor and outdoor communal areas. Service users are encouraged to maximise their independence by having access to the range of specialist equipment supplied by the home. Infection control procedures could be improved. EVIDENCE: The home generally is homely and clean. It is fairly well maintained but is starting to show sign of wear and tear. Several of the bedrooms were in need of redecorating. One family who were visiting were concerned that when their Mother recently moved into the home the wallpaper in her room was torn and the carpet smelt of urine. The inspector visited the room with the family and no improvements had been made. It will be recommended that the home should carry out an audit of the bedrooms to identify which ones require redecorating and to prepare a programme of routine maintenance and renewal Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 18 of the fabric and decoration. This will then need to be implemented and records kept. Some of the toilets and sluice rooms could also be improved and were in need of redecoration. The home was well equipped with specialist equipment, which met the needs of the service users. Hoists and assisted bath were regularly serviced. Every room had access to the call system and service users confirmed the calls were answered promptly. The gardens were ell enjoyed by the service users and appeared safe and secure. Bedrooms were well personalised and again service users confirmed they were encouraged to bring on personal items to decorate their own rooms. Several were in need of redecoration. One area of concern was the system in place to deal with clinical waste. During the inspection several bags of soiled incontinence pads were seen left on top of the billies that contained dirty washing. Some staff did not appear to know whose responsibility it was to remove these. Several bins in the toilets were seen to be overflowing with pads, some without lids. It will be a requirement that a procedure is implemented to ensure the control of infection including the safe handling and disposal of clinical waste. Staff confirmed that sufficient protective clothing was available. All radiators in the service users bedrooms and lounges were guarded, however radiators in the corridors were not and this should be addressed. Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 Services users benefit from being cared for by staff who have a good understanding of their needs though staff shortages have resulted in them not always receiving consistent care. Residents benefit from staff that are trained and competent to do their jobs and who enjoy good morale. EVIDENCE: Figures given by the home confirmed it has 624 vacant care hours per month. This accounts for the high number of agency staff used. The Support Service Assistant (clerical) was also 20 hours short. There has been a period of instability within the workforce with only temporary or acting posts being offered. The home needs to now recruit permanently to these vacant hours as soon as possible. Discussion with the manager confirmed that work has starting on this project and she was hopeful that these hours would be filled soon. The home currently has 45.5 of its staff qualified to NVQ level two or above. The Acting Manager was aware that this falls slightly below the required level pf 50 but she stated that some staff were working towards their awards and she hoped to meet the 50 figure very soon. The home did not have a training matrix so it was difficult to assess what training had been provided. The manager was advised to ensure a fully Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 20 updated matrix is prepared to ensure the staff are fully trained and that any future training can be planned. The manager was able to provide a list of training completed in the last 12 months that was comprehensive but was unable to say who had completed each individual course. Several staff commented that they were waiting for First Aid training. Kent County Council have robust recruitment procedures in place to ensure service users are protected. Four staff files were viewed and one was found not to have a CRB check and one CRB was from another home. A requirement will be made that all members of staff have a current CRB applied for by the home and this information be recorded securely. This was discussed with the Assistant Manager during the second day of the inspection. Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The service users benefit from having a manager who is well supported by senior staff in providing clear leadership throughout the home and by staff who demonstrate an awareness of their roles and responsibilities. Residents do not benefit from having staff that receive regular supervision. Current arrangements were sufficient to protect the health, safety and welfare of residents and staff. EVIDENCE: The official Registered Manager was on secondment and an Acting Manager had been appointed. It became clear during discussion with the Acting Manager that several posts within the organisation were currently designated as Acting positions. A new Director had now been appointed and it was hoped that these position could now be advertised as permanent positions. The Acting Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 22 Manager appeared to have managed the service well during the time of her appointment and was confident that the home was run in the best interests of the service users. Some of the areas of concern raised in the report could be easily managed by better monitoring of practise and once pointed out the Inspector felt confident the Acting Manager would take appropriate action. The Acting Manager was unsure if formal any quality assurance questionnaires were available to services users and or their representatives but confirmed that fairly regular residents meetings take place. Staff meetings and senior staff meetings also take place. The home complies with Regulation 26 and details of the reports are sent directly to the Commission. Quality Assurance is an area that would benefit from being improved and it is advised that the organisation actively seeks and records feedback from service users and of families, friends and of stakeholders in the community such as G.P’s, chiropodists etc on how well the home is achieving its stated goals. The results of these surveys should be published and made available to current and prospective users and their representatives, including the Commission (33.6). Discussion also took place regarding the annual development plan based on systematic cycle of planning, action and review reflecting the aims and outcomes for service users. Due to the disruption in the role of Registered Manager this appeared to have been overlooked. It was noted that two of the requirements made at the last inspection have not been fully complied with and these requirements will remain in place. Suitable accounting and financial procedures were in place to ensure effective and efficient management of the business. Adequate insurance policies were in place as required by regulation. The home only deals with the monies of one service user. Due to the insufficient clerical hours being available these records had not been updated for three months, however this was addressed during the inspection. The personal monies of this service user should not be pooled and it is advised that the money is kept separately. The home does have a safe available for the safekeeping of monies and valuables on behalf of the service users. Records were kept of the contents of the safe. At the last inspection a requirement was made regarding staff supervision. Records indicated and conversations with staff confirmed that this is still not occurring regularly. Supervision must occur at least six times a year and records must be kept. This is across all levels of the staff group. Some staff confirmed that they felt well supported by senior staff and others felt the supervision they had received was in effectual and the outcomes had not been as expected. The Acting Manager needs to take action to ensure that supervision covers all aspects of care, the philosophy of care in the home and career development needs as stated in the Minimum Standards and to ensure that staff have the right expectations of the role of supervision. The Acting Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 23 Manager was advised to look on the guidance notes on the Commissions website. Evidence seen during the inspection indicated that so far as is reasonably practicable the health, safety and welfare of service users and staff was maintained. As indicated in a reports seen on the day, some of the thermostatic mixers valves need to be replaced. Care planning issues have been covered earlier in the report. Kiln Court DS0000037750.V302308.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 3 3 4 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 2 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 3 2 2 3 3 Kiln Court DS0000037750.V302308.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 OP29 Regulation 19 (4)(b)(i) Requirement Timescale for action 30/09/06 2 OP36 18(2) 3 OP7 15(1) and (2)(a-d) The Registered person shall not allow a person to whom paragraph (2) applies to work at the Care Home in a position which paragraph (3) applies, unless (b)(i) the employer has obtained in respect of that person the information and documents specified in paragraphs 1 - 7 of Schedule 2. In that Current CRB’s are recorded. This has been carried over from the last report. The Registered person shall 30/09/06 ensure that the persons working at the home are appropriately supervised; that is at least 6 times a year and records kept. This has been carried over from the last report. Unless it is impracticable to carry 31/10/06 out such consultations, the registered person shall, after consultation with the service user or a representative, prepare a written plan as to how the service users needs in respect of health and welfare are met. DS0000037750.V302308.R01.S.doc Version 5.2 Kiln Court Page 26 4 OP19 23(1)(a) (2)(b)(d) 5 OP26 13(3) 6 OP25 13(4)(a) (1)The registered person shall 31/10/06 having regard to the number and needs of the service users ensure that the premises are suitable for the purpose of achieving the aims and objectives set out in the purpose of statement, (2)(b) The premises are of sound construction and kept in a good state of repair externally and internally; (2)(d) All parts of the home are kept clean and reasonably decorated. A programme of routine maintenance and renewal of the fabric and decoration of the premises is required. The registered person shall make 30/09/06 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. The registered person shall 31/10/06 ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. In that radiator covers are fitted in all areas including corridors. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Kiln Court Refer to Standard OP25 OP29 Good Practice Recommendations It is recommended that the required replacement of the Thermostatic Mixer Valves be completed as soon as possible. It is recommended that records of all CRB checks be fully DS0000037750.V302308.R01.S.doc Version 5.2 Page 27 3. 4. 5 OP30 OP33 OP33 maintained in the home. It is recommended that there is a staff development and training programme maintained in the home. It is recommended that quality assurance in the home be improved. It is recommended that an annual development plan based on a systematic cycle of planning, action and review is written. Kiln Court DS0000037750.V302308.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Kiln Court DS0000037750.V302308.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!