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Inspection on 15/07/08 for Kimberley Nursing Home

Also see our care home review for Kimberley Nursing Home for more information

This inspection was carried out on 15th July 2008.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

As an existing care home many of the rooms would not meet new standards relating to size and there are still some areas, which would benefit from redecoration and refurbishment. However, it provides a safe and generally homely, environment for its residents. The responsible person is aware of the areas that still need attention and there are plans in place to address them. Major expenditure on new equipment over the last year has lead to delays in implementing these. All parts of the home are accessible to people who have limited mobility and there are both a stair lift and a passenger lift to help residents who need to go upstairs. Residents look very well cared for and they told us that they are happy living in the home and staff are kind and caring. One resident said that "they (staff) were always so polite" and another that "they were always there to help you". Many of the staff have worked in the home for some time and this provides familiarity for residents and continuity of care. There are both trained nurses and carers throughout the 24-hour period and rotas show there are always enough of them to meet the healthcare needs of the residents. The acting manager who is in the home during the week is also a nurse. People are able to choose how they spend their days. A limited range of activities are arranged for those who wish to join in while others prefer to stay in their rooms and read or watch television. Occasional trips out of the home are organised and entertainers visit regularly. People told us that the food served in the home was "always good" and "there are always nice dinners here". Choices are always available and it was noted that special requests were catered for without any problems. Everyone confirmed that should they experience any concerns or problems they were confident that they would be dealt with promptly. The Responsible Person for the home is often on the premises and available to both residents and their relatives. Records show that complaints are taken seriously and managed appropriately.

What has improved since the last inspection?

Since the last inspection the redecoration programme has started. The corridors and hallways and some bedrooms have been painted, a new stair lift has been installed, and carpets were due to be laid during the week following the inspection. In addition the kitchen has been upgraded with new units and tiling. An investigation into an incident in the home highlighted deficiencies in moving and handling equipment and training. This has now been addressed. New beds and hoists have been purchased and training has improved. Residents, who needed them, have had their moving and handling assessments reviewed and have new care plans in place so that all members of staff are aware of the correct procedures to be followed. The acting manager has undertaken training, which will enable her to train other members of staff in the home. Organised activities in the home have been increased for those residents who wish to join in. An activities organiser is in the home three times a week and outside entertainers are being booked to come in to the home. One lady told us " I like it when the lady comes, she has a big bag of things and we play games".

CARE HOMES FOR OLDER PEOPLE Kimberley Nursing Home 51-53 The Avenue Surbiton Surrey KT5 8JW Lead Inspector Alison Ford Unannounced Inspection 15th July 2008 11:00a 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 Kimberley Nursing Home DS0000026250.V368073.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. Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kimberley Nursing Home Address 51-53 The Avenue Surbiton Surrey KT5 8JW 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) 0208 390 1557 020 8390 4372 kimberleynursinghome@yahoo.co.uk Partnership of Parkin, Blown and Blown Post vacant Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability over 65 years of age of places (38) Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th July 2007 Brief Description of the Service: Kimberley Nursing Home is registered with The Commission for Social Care Inspection to provide nursing care for up to thirty-eight older people. Accommodation is arranged in a mixture of single and shared rooms over three floors. There is a large lounge and dining room and an attractive wellmaintained rear garden, which is well used by the residents. All areas of the home are accessible to residents, including those who may have limited mobility, and a passenger lift, specialist adaptations and equipment have been provided. The home is situated in a quiet residential road in Surbiton and there is off street parking to the front of the property. Fees at the time if this inspection range from £530-£720 according to the dependency of the resident and would be discussed prior to admission. Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate, quality outcomes. This was the homes first key inspection visit as part of the inspection process for the year 2008/2009 and was unannounced. When writing the report consideration has also been given to other information gathered throughout the year such as, records of accidents and complaints and other documentation required to be kept by the home. There have also been conversations with residents, their relatives and members of staff. On the day of the visit there were 24 residents living in the home although 1 person was in hospital. In addition to the manager, two trained nurses were on duty with four care staff, supported by a cook, and domestic staff. We undertook a tour of the premises, looked at a sample of care plans and spoke with several of the residents about what it was like to live in the home. We also looked at some of the documentation that the home is required to keep as evidence of its commitment to the health and safety of its residents and spoke with some of the staff that were on duty. Previously, concerns had been raised about moving and handling procedures, following an incident in the home. This resulted in the local authority stopping placing residents in the home although; people who were privately funded were able to decide for themselves if they wished to live there. The situation was closely monitored both by The Commission and the placing authority and the issues have now been resolved in line with local safeguarding procedures. Extra equipment has been purchased, staff training has been improved and there are no longer any limitations on placing people in the home. No further concerns have been raised about the home. The management team have not, as yet, returned their Annual Quality Assurance Assessment to us although they have been reminded that it is due. This is a document in which they tell us about their service and how it meets the needs of the people who live there and also about their plans for the future. The timescale has been extended however, this is a legal requirement and advice will be taken from the enforcement team regarding future action to be taken if it is not returned. Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 7 Since the last inspection the redecoration programme has started. The corridors and hallways and some bedrooms have been painted, a new stair lift has been installed, and carpets were due to be laid during the week following the inspection. In addition the kitchen has been upgraded with new units and tiling. An investigation into an incident in the home highlighted deficiencies in moving and handling equipment and training. This has now been addressed. New beds and hoists have been purchased and training has improved. Residents, who needed them, have had their moving and handling assessments reviewed and have new care plans in place so that all members of staff are aware of the correct procedures to be followed. The acting manager has undertaken training, which will enable her to train other members of staff in the home. Organised activities in the home have been increased for those residents who wish to join in. An activities organiser is in the home three times a week and outside entertainers are being booked to come in to the home. One lady told us “ I like it when the lady comes, she has a big bag of things and we play games”. What they could do better: People thinking about coming to live in the home, have an assessment, done by a senior nurse, to make sure that the home will be suitable for their needs. These still need to show that resident’s social preferences and abilities have been considered as well as their physical needs so that they can decide if the daily life in the home will suit them. The information that is given to them during the admission process also needs to be updated to make sure that it reflects the current situation in the home. Similarly, care plans should reflect that thought is being given to resident’s social needs as well as their physical ones. In order to do this effectively more information must be available about their past lives and achievements. This will allow staff to understand the behaviour of the people that they are caring for and also to plan activities that will interest them. In order to make sure that the home remains a pleasant place for people to live in the redecoration and refurbishment programme must continue. It was also noted that the laundry now needs to be upgraded. In order to help with infection control it will need new flooring which is impermeable and wall covering which is easy to keep clean. Some work is also required to make sure that the garden remains safe for anyone who wishes to walk around out there and also for staff. Staff training is ongoing in the home and mandatory sessions in fire safety, moving and handling and safeguarding have been completed. There now needs to be more of an emphasis on issues, which help staff to understand more Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 8 about the problems that are experienced by older people. These might include topics such as infection control, dementia awareness and The Mental Capacity Act. Recruitment procedures were assessed and it was noted that there were not always 2 references received prior to new members of staff being employed. Residents in the home must be protected from people who have been judged as being unsuitable to work with vulnerable people and there must be 2 written references available for every staff member. Where verbal references are gained these must be followed by a written version at a later date. The home must implement some form of quality assurance monitoring tool. Although several thank you letters are displayed, there is no formal method of gaining the views of the people who use the service. Periodic questionnaires, surveys or meetings would allow residents and their relatives to comment on the care and services that are provided and contribute their ideas. 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. Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 9 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 Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 10 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): Standards 1,3, 6 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A pre-admission assessment is undertaken to make sure that the services and facilities that are provided by the home will be sufficient to meet the needs of anyone considering moving in. This home does not offer intermediate care: this standard does not apply. EVIDENCE: This home has a basic admission procedure however, it is not particularly personalised and there is little evidence to show that consideration is given to peoples concerns or anxieties. Anyone wishing to move into the home would have an assessment undertaken by a senior nurse to ensure that their needs can be met. For those people who are funded through local authority arrangements the home would also have a copy of the care manager’s assessment. Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 11 No new people have been admitted since the visit to the service however; the acting manager undertook an assessment on the day of this inspection. Basic information regarding resident’s physical health and capabilities was collected although there was limited information about their social needs and preferences which would help to determine if the daily life and routines in the home would suit them. There is no brochure or information pack to take to prospective residents to show them what the home is like and although there is a Service User Guide it is written in a standard format rather than one which would be easy for older people to read. This document still does not contain information about the range of fees that are payable despite previous requirements. It is also out of date in as much as it contains details of then previous matron. The responsible person has agreed to address this therefore the timescale will be amended. Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 12 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): Standards 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service have an individual plan of care, which reflects all of the care and support that they require to meet their healthcare needs. More information regarding their social preferences and achievements would mean that staff would understand more about them and activities could be tailored to suit their interests. The arrangements that are in place for delivering personal care ensure that residents can be sure that their dignity and privacy will always be respected and medication procedures are in place to protect them. EVIDENCE: The care plans of five residents that were spoken with during the course of the inspection were looked at. The information in them was well organised and would allow staff who were unfamiliar with residents to understand how they need to be supported. It was noted that some entries were rather generalised Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 13 as in “good day” or “slept well” and the need to make them more detailed was discussed with the manager. The care plans include risk assessments, detailed moving and handling plans, nutritional assessments and monitoring of factors, which could lead to the development of pressure sores. There is evidence to show that they are regularly reviewed so that they remain up to date however, it would seem that residents or their families are not always able to contribute to them. It is considered that some of the residents in the home would be able to make decisions about aspects of their care and influence the way that they are supported and care plans should show that they have been given an opportunity to be involved. The care plans show that there is involvement from other healthcare professionals where it is needed and the doctor visits regularly. Appropriate equipment is in use to help those with reduced mobility and prevent pressure sores and the home has recently purchased several new nursing beds and new moving and handling equipment. Some time was spent sitting in the lounge chatting with residents while the manager was away from the home. Everyone agreed that the staff in the home were very caring, kind and helpful and it was a nice place to live in. All of the residents looked clean, happy and well cared for. They were all well groomed and ladies had been helped to put their make up on and some were wearing nail polish. A sample of medication stores and records were seen and these were all in order. Record sheets all have photographs on to minimise the risk of errors and there is a signature list of those trained to give medication so that it would be easy to investigate any discrepancies. Kimberley Nursing Home DS0000026250.V368073.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): Standards 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents find that the lifestyle in this home generally suits their needs and that they can choose how they spend their days. Their friends and relatives are always welcome to visit and they enjoy the meals that are served to them. EVIDENCE: The residents that we spoke with agreed that they are able to choose how they spend their days, the clothes that they wear and the meals that they eat. At the time of the visit the majority of them were in the lounge although there were some who chose to stay in their own rooms and read or watch television. They told us that their visitors were always welcome although it was observed that staff do not always greet them when they come into the home. Since the last inspection the range of activities that are offered to residents has increased and an activities organiser comes into the home three times a week. Apparently at other times the care staff sit with residents and sometimes play games with them although this was not happening on the day Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 15 of the inspection. We were told that outside entertainers also visit the home on a regular basis although; one resident did say that she gets very bored in the home at times. It was suggested that some consideration might be given to rearranging the chairs in the sitting room to encourage more interaction between residents. It is also recommended that staff should maintain a list of the activities that are offered to residents and indicate whether they decided to join in with them and the reasons that they might have decided not too. The lunchtime, meal was served during the inspection. It looked appetising and well presented and residents agreed that the food served in the home was very good and that they are always offered a choice. Particular preferences and diets can be catered for. The mealtime seemed to be a pleasurable experience for residents most of whom eat together in the dining room. There were enough staff to help people who needed it and adapted crockery was in use for those with limited dexterity. Kimberley Nursing Home DS0000026250.V368073.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): Standards 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents say that they are sure that any concerns they might have would be dealt with promptly. Staff have the knowledge and training to respond to any allegations of abuse and recruitment checks ensure that people who have been judged as unsuitable to be working with vulnerable adults are prevented from doing so. EVIDENCE: There is a complaints procedure within the home that meets the National Minimum Standards and regulations. This is included in the documentation that is in resident’s bedrooms. Everyone who was spoken with said that if they had any concerns they would tell the staff and they would deal with it. Complaints are recorded in a book with the actions taken to resolve them and any outcomes arising from them. Staff that were spoken with displayed an understanding of procedures to be followed to ensure the safety of the people who use the service. They knew how they should report any allegations of abuse and said that they would feel confident enough to do so. No new member of staff is appointed without satisfactory clearance from the Criminal Records Bureau. Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 17 Since the last inspection there has been one concern raised about the home which involved moving and handling practices in and several meetings were held to discuss the issues. Since that time, extra equipment has been purchased and the local authority’s moving and handling advisors have provided training. Kimberley Nursing Home DS0000026250.V368073.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): Standards19, 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is clean and tidy and some redecoration and refurbishment has begun. This will need to continue in order to provide a pleasant environment for the people living there. EVIDENCE: The location and layout of the home are generally suitable for the people who live there. It is clean and comfortable and adaptations are place to help those with reduced mobility. Bedrooms are comfortable and residents have been encouraged to personalise them with items from home. There are assisted bathrooms and toilets throughout the home. The premises comply with current fire safety legislation and there is a nurse call system in place. The kitchen has recently been refurbished and a recent Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 19 visit from the environmental health department resulted in a three star rating being awarded. Previous inspections have highlighted the fact that much of the home requires decorating and this has now started. The lounge and hallways have been painted and at the time of this inspection new carpets were about to be fitted. A new stair lift has been installed. It is planned to alter the downstairs bathroom and make a shower room, which will offer more choice to residents. However, it was noted that the laundry also needs to be upgraded and new suitable floor and wall coverings put in place. Some bedroom carpets also need to be replaced although we were told that this is planned. There is a pleasant well-maintained garden to the rear of the home although there is unwanted equipment stored out there, which must be moved. There is also some broken paving which must be repaired. On the day of the inspection the home was clean and tidy and free from odour. Kimberley Nursing Home DS0000026250.V368073.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): Standards 27,28,29,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service There are always enough staff on duty to meet the needs of the residents however, they would benefit from an increase in training relating to the problems that are associated with older people. Recruitment procedures must be improved to minimise risks to the safety of residents. EVIDENCE: The home is staffed by trained nurses and care staff throughout the 24-hour period who are supported by a range of ancillary staff. Off duty rotas showed that there are always enough staff on duty to meet the needs of the residents who told us that they didn’t have to wait too long when they wanted help. There has been a limited amount of staff training since the last inspection. All of the staff have received training in moving and handling, safeguarding procedures and health and safety. Fire training is booked for later this year. In order to address the needs of the residents in the home, staff training needs to be improved to included issues, which relate to older people. It is recommended that these might include topics such as infection control, dementia awareness and the Mental Capacity Act. Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 21 The personnel files of two new staff members were seen. It was noted that in both cases only one reference had been received prior to them starting work. In order to help to ensure the protection of the people who live in the home, there must be two references available for all staff even if one is a verbal reference, which is then followed up by a written version. Kimberley Nursing Home DS0000026250.V368073.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): Standards 31,33,35,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live in the home do not have any formal method of contributing their views and influencing the way that the home is run. Policies and procedures are generally in place to safeguard their health and safety however, documentation that should give us important information about the service has not been returned on time. EVIDENCE: Since the last inspection a new acting manager has been appointed to the home and The Commission is waiting for her application to assess her knowledge and suitability. She has previously worked in the home for some time however the application process will confirm her suitability for this role. Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 23 At the last inspection there had been some progress with regard to gaining information from residents about services that are provided by the home. This has not been continued although we did see several thank you letters on the wall written by relatives of people who had lived in the home. There are no residents / relatives meetings and no formal method way of them influencing the way that care is provided. This is an area that must be addressed so that the management team are confident that residents and their relatives are receiving a service that suits them and meets their needs. It is acknowledged that the representatives of the owners of the home spend a lot of time in the home and monitor its daily running. However, there is still no documentary evidence, in line with Regulation 26, to show that they speak with staff and residents to ensure that they are happy with everything in the home. The home does not take responsibility for the finances of any of the residents. They all have relatives or representatives who are able to help them with this. There was evidence to show that the maintenance of equipment and services in the home is appropriate and hot water temperatures are now being monitored regularly. The Annual Quality Assurance Assessment had still not been returned at the time of writing this report. This document gives us information about the home and how well it considers that it is meeting the needs of the people who live there. It also tells us about their plans for their future. There is a legal requirement for this to be returned on time and although an extension has been given, in view of time constraints as a result of work being undertaken, a repeated lack of compliance may lead to enforcement action being taken against the home. Kimberley Nursing Home DS0000026250.V368073.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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 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 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 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 2 Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP1 Regulation 4,5 Requirement The Service User Guide and Statement Of Purpose must be amended to show the range of fees payable and the new management structure. The pre-admission assessment that is undertaken must reflect people social needs and preferences in order to show that they can be met by the home. Care plans must reflect residents past life history and achievements so that activities can be arranged which suit their interests and staff are able to understand more about the people that they are caring for. Care plans must provide evidence that residents or their families have been involved in deciding how they wish to be supported. Unwanted equipment must be removed from the garden and paving repaired in order to make it safe for residents. The laundry area must be DS0000026250.V368073.R01.S.doc Timescale for action 30/10/08 2 OP3 14 30/10/08 3 OP7 15 30/10/08 4 OP7 12(3) 30/10/08 5 OP19 13 (4)(a) 30/10/08 6 OP26 23(2)(b) 30/10/08 Page 26 Kimberley Nursing Home Version 5.2 7 OP29 19(4) Schedule 2 8 OP30 18(1)(c) 9 OP33 12(3) 10 11 OP33 26 CSA 31(9) OP38 upgraded with suitable floor and wall coverings, which can easily be cleaned, to help stop cross infection. Two written references must be available for every member of staff currently working in the home in order to help protect people who use the service. Staff training must be increased in order to help them understand more about the issues that affect the people that they are caring for. A quality assurance system must be developed which monitors the views of the people who live in the home and gives them the opportunity to influence the way that the are and services are delivered. Visits to the service made in line with regulation 26 must be documented. The Annual Quality Assurance Assessment must be completed and returned as required. 30/07/08 30/10/08 30/10/08 30/10/08 10/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations It is recommended that a brochure or information pack could be produced to help with the pre-admission process. Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Kimberley Nursing Home DS0000026250.V368073.R01.S.doc Version 5.2 Page 28 - 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. 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