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Inspection on 27/07/05 for Kingfisher House Residential and Nursing Home

Also see our care home review for Kingfisher House Residential and Nursing Home for more information

This inspection was carried out on 27th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

Kingfisher House offers a clean, well maintained, and attractive environment. All residents spoken with said that they are happy with the service they receive Observed interaction between staff and service users was found to be positive and respectful. Care plans are monitored and updated regularly. Two residents spoken with said, "They were happy" "the food is good". Other comments received included "staff are always cheerful and helpful", staff are respectful of privacy and help me with a bath", "if I had a complaint I would talk to staff" "they are always willing to listen". One resident commented about being able to see the garden from their bedroom and said "I like it here and like to watch the birds and squirrels" "I prefer my room but like to have lunch with the other residents. Relatives were also complimentary about the care provided to the residents. One relative was concerned about the health of a resident but said, "The nurses are very good they explain and reassure me." Other relatives commented on how nice the residents looked. Only one less than positive comment was received about the availability of commodes but in the context that staff have to spend time finding the equipment. One relative also commented that communication between them and the home was good.

What has improved since the last inspection?

The recording of the condition of pressure sores has improved. The record now includes detailed information about the area and including the size of the pressure area and the date the area was reviewed and redressed. A further development could be to include the condition of the infected area when reviewed. There was also evidence of monitoring residents who have been assessed as being at risk of developing a pressure sore.

CARE HOMES FOR OLDER PEOPLE Kingfisher House St Fabians Close Newmarket Suffolk CB8 0EJ Lead Inspector Anna Rogers Announced 27 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Kingfisher House Residential and Nursing Home Address St Fabians Close Newmarket Suffolk CB8 0EJ 01638 669919 01638 669929 kingfisher.house@fshc.co.uk Mr Louis Smith Four Seasons Homes No 4 Limited Mrs Deborah Canning (N) Care Home with Nursing 62 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Category(ies) of OP Old Age (62) registration, with number DE(E) Dementia over 65 years of age (4) of places DE Dementia (4) Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate up to 62 persons, of either sex, requiring care and accommodation by reason of old age (over the age of 65 years) 2. The home may accommodate up to 4 persons, of either sex, over the age of 60 years requiring care and accommodation by reason of dementia 3. The maximum number accommodated must not exceed 62 Date of last inspection 7th February 2005 Brief Description of the Service: Kingfisher House, Newmarket is part of Four Seasons Health Care. It is purpose built to provide nursing and residential care for a maximum of 62 older people. Kingfisher House has two floors with a shaft lift accessing the first floor. The home has a lounge on each floor, a smoking room and a laundry room situated on the ground floor. Both floors have seperate dinning rooms which are available for service users to eat their meals. There are 58 single bedrooms and four shared rooms each having the advantage of an en suite toilet and wash basin, shared bathrooms are situated on each floor. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place on Wednesday 27th July 2005 over 7 hours starting at 10.00 am. The registered manager has been promoted within the company. A Registered manager from another home within the company is currently managing Kingfisher House. Evidence for the inspection was gathered from a variety of sources. The preinspection questionnaire provided information regarding residents and staff. A number of records were examined including those relating to the care of residents and staff records. A tour of the home was undertaken. Three comment cards were received from residents and three from relatives/visitors. Two relatives/visitors were also spoken with during the inspection. Time was spent with eight staff on duty including the acting manager. Twelve residents were spoken with individually and others including a group of six were spoken with informally in one of the resident’s lounges. What the service does well: Kingfisher House offers a clean, well maintained, and attractive environment. All residents spoken with said that they are happy with the service they receive Observed interaction between staff and service users was found to be positive and respectful. Care plans are monitored and updated regularly. Two residents spoken with said, “They were happy” “the food is good”. Other comments received included “staff are always cheerful and helpful”, staff are respectful of privacy and help me with a bath”, “if I had a complaint I would talk to staff” “they are always willing to listen”. One resident commented about being able to see the garden from their bedroom and said “I like it here and like to watch the birds and squirrels” “I prefer my room but like to have lunch with the other residents. Relatives were also complimentary about the care provided to the residents. One relative was concerned about the health of a resident but said, “The nurses are very good they explain and reassure me.” Other relatives commented on how nice the residents looked. Only one less than positive comment was received about the availability of commodes but in the context that staff have to spend time finding the equipment. One relative also commented that communication between them and the home was good. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 Residents are provided with information they may need to make an informed choice about where to live and have their needs assessed and can expect that these needs will be met EVIDENCE: Kingfisher House provides a statement of purpose, providing information on the provision of care to be provided and how they will meet the needs of individual service users. Six care plans were seen which provided evidence that assessments had been completed prior to admission. The assessment format had not been completed in all cases with some sections recording no information for example the sexuality section. The acting manager said that some sections are completed once the resident is in residence but agreed to look at how this is done. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10, 11 Residents cannot be assured that their care plan will set out their needs. Residents can expect that their health needs are met and at the time of death their choices will be respected. Residents feel they are treated with respect and their right to privacy is upheld. Administration of medicines is not currently effective. EVIDENCE: Six care plans were inspected and related to residents admitted over the last three years. As noted in the previous section admission assessments had been undertaken. Care plans do not show that they have been agreed or signed by resident or their representative. There was evidence that care plans are updated monthly. Each plan consisted of separate components of care to reflect the individual sections of the assessment. There is space on each component for staff to report on how the need is being addressed. There is also a progress sheet for staff to record general areas of progress not necessarily related to the care plan. From the sample seen it was clear that staff are using the progress sheet to comment on components of the care plan instead of using the evaluation of Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 10 care section at the bottom of each component. There is also a need to date entries made on the progress sheets including the year. The plans identify how service users health and personal needs are met. Risk assessments were available particularly for moving and handling. Inspectors observed the communication between staff and residents who remain in bed. Their progress notes highlighted issues around food, toileting and sleep, but did not reflect the positive time staff spent with residents and how they responded to this stimulation. Four of the care plans looked at recorded residents wishes at the time of death, for example burial or cremation. Residents spoken with all stated that they are happy and comfortable at Kingfisher House; one service user said ‘you won’t have any problems with me, this is my home’. Residents said they are treated with respect and their privacy and dignity is upheld at all times. One visitor who was spoken with stated that the care their relative is provided is ‘very good and cannot be faulted, the staff are very caring’. Staff were observed to knock on doors before entry to residents bedrooms. Inspectors observed that the interaction between staff and service users and staff and visitors was friendly, respectful and positive. It was noted that where two residents share a bedroom privacy is respected and residents had a choice of using the curtain available between the individual residents space. The home uses a Monitored Dosage System (MDS) and trained nurses are responsible for the ordering, storage, administration and disposal of unused medication. The Medication Administration Records (MAR) sheets were found again to have unexplained gaps including no signature of anyone administering medication and no explanations for this. This was found to have occurred for four residents on nine separate occasions. There was also one residents’ medication showing they had not been given their medication on the morning of this inspection but when discussed with the nurse on duty they said they were sure this had been given but from medication left in the blister pack for a previous day. The records did not support this. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Residents can expect that the lifestyle experienced in Kingfisher House matches their expectations and preferences. Residents are provided with assistance in exercising choice and control over their lives and are supported in maintaining contact with others as they wish. Not all residents can expect to be provided with an appealing meal in pleasing surroundings. EVIDENCE: One resident was dusting their bedroom, and said they like to keep themselves busy in the home or out in the garden when the weather is better. The domestic member of staff was observed to helping the resident when requested by the resident for example, to dust the top shelf. The inspector observed the positive and respectful interaction between the resident and member of staff. Inspector asked the service user if they wished to do more in their room, service user said they hadn’t really thought about asking but is sure it would be supported if they did. Two residents said they would like more activities, one stating that they were bored with knitting and bingo. Several residents said that they liked playing scrabble but they did not do this anymore because the Activities Co-ordinator had left two weeks before. The residents did say that other members of staff do try but they don’t have as much time as the designated person did. The acting manager stated that the vacant post has been advertised. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 12 There was evidence that staff do undertake individual activities with residents, for example manicures and nail painting and hand massages but this was not routinely evidenced in records. Three residents spoken with had books in their rooms and they confirmed they enjoyed reading. The residents said the library service visits the home weekly and provide an en excellent service. One resident said “if I want a special book they’ll always get it for me”. An inspector spoke with a group of six residents sitting together in a lounge area, they all said that they were happy at Kingfisher House. One resident said that if they wished to go out they are supported in doing so. Another resident spoken with individually in their bedroom showed the inspector their painted fingernails, which had been done by a member of staff, and were clearly very pleased with the colour. A hairdresser was at the home at the time of this inspection. One resident spoken with said they were very happy with hair and stated that the hairdresser had asked what they had wanted done. Residents spoken with said that their visitors are welcomed to visit Kingfisher House. One resident said they don’t get many visits as their family are dispersed around the country but they received regular telephone calls and letters. Resident’s bedrooms were personalised with photographs of family and one resident had a small refrigerator in their room with drinks and snacks and said they liked to spend the majority of their time in the privacy of their own room. Residents are able to choose if they wish to eat meals in their bedroom or in one of the dining rooms. Dining rooms are light and attractive and provide good space to assist residents with mobility difficulties. Residents spoken with commented favourably on the food and choice of meals offered. Staff were observed to asking residents what they would like and served each meal individually. The mealtime was unhurried with staff assisting when necessary. Two members of staff were observed feeding two residents. They were positioned outside the main dining area, which was also used as a walkway through the dining area to other parts of the home. Each staff member was positioned at the side of the resident requiring assistance one was being helped to eat a pureed meal. It was observed that there was little interaction between the member of staff and resident, for example what the resident was being offered or were they enjoying it. Another resident was being assisted by a member of staff using a large desert spoon, which was heaped with food each time the meal was offered. Again there was no interaction between this member of staff and resident regarding what they were being offered. At one point a colleague came up to one of the staff and asked a question, this was responded to, but at no point did the member of staff excuse themselves from helping the resident with their meal. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 13 Staff were observed serving hot drinks and biscuits to service users throughout the day, in either the lounge or own rooms with a choice of drink and biscuits given. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Residents can expect that their complaints will be listened to, taken seriously and acted upon and they are protected from abuse EVIDENCE: Residents spoken with said that they would know who to go to if they have a complaint, and felt their concern would be dealt with. Staff spoken with clearly knew where to go to report any incidents of bad practice. Staff spoken with indicated that they had in the past reported a concern they had and felt that issue has been dealt with effectively and efficiently by the senior member of staff on duty. Staff spoken with were aware of the Protection of Vulnerable Adults (POVA) policy and procedure, but it was not possible to confirm if training was up to date as training records were not available. One complaint has been made to the home since the last inspection. There was evidence that the complaint was dealt with within 48 hours and the record shows that the complainant was satisfied with the verbal response given by the manager although a written response had been offered. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, 26 Kingfisher House is well maintained, pleasant and clean. Resident’s bedrooms and communal rooms are safe and comfortable and sufficient to meet resident’s needs. EVIDENCE: Kingfisher House is an attractive and well-maintained home. Grounds are tidy and attractive; though the front of the home is currently being used for equipment while an additional 29-bedded unit is being completed. This area had been secured to reduce entry to the new site by residents. During this visit the acting manager advised inspectors that the fire safety company was visiting to deal with a problem with the closing of a fire safety door. The acting manager confirmed at the end of this inspection that this had been dealt with. It was noted during the tour of accommodation that a door to the staff room on the first floor was held open by a chair; this was brought to the attention of the senior nurse who removed the chair and said they would speak with staff to ensure fire doors were not wedged open. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 16 Furnishings and décor in communal areas are comfortable, well maintained, and attractive and are suitable for use by residents. The lounge and dining rooms are light having the advantage of large windows. Sluice rooms are situated in corridors, separate from other facilities. All bedrooms have en suite toilet and sink facilities and there are shared bathrooms and toilets throughout the home. All areas seen were noted to be clean, have grab rails and were provided with paper towels and liquid soap dispensers. Hoists are positioned near to bathroom and toilet facilities, in a way, which does not pose a risk to individuals passing by. Baths have bath seats available for residents use. Call systems are available in every room. Temporary storage for wheelchairs and linen for the extension is currently being stored in a ground floor lounge, which is usually used for meetings and staff training. Residents walking frames and wheelchairs were observed to be accessible to them, in working order and well maintained. The home has a shaft lift and stairways between the two floors. Residents private bedrooms are comfortable, well maintained and homely, all provided with adequate furnishings. All rooms observed had service users personal possessions, such as plants, flowers, photographs, pictures, books and ornaments, each having service users individuality reflected in them. One resident was reading in the first floor corridor and stated that the lighting was better there. This was discussed with the acting manager who said that reading lamps were available and they would ensure the resident who has recently been admitted was provided with one. Kingfisher House is clean with free from unpleasant odours. The laundry room was observed to be tidy, residents clothing was ironed and hung on clothes rails waiting to be returned to the resident’s bedrooms. A concern was expressed by members of staff regarding the shortage of gloves and wipes for personal care with residents. This was followed up and the issue is not about the shortage it is about where the extra supplies are stored when staff run out. The acting manager said they would review where the supplies are kept and ensure a system is introduced which ensures stock is available on each floor. Staff spoken with said they have raised concerns about the shortage of commodes. A relative also commented about this in their feedback card to The Commission for Social Care Inspection (CSCI). Although the acting manager confirmed that these have now been ordered it is clear that an effective system must be arranged to ensure supplies of equipment are adequate. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 30 Residents can expect their needs to be met by the numbers and skill mix of staff. EVIDENCE: Evidence of staff training was not available to inspectors. Two members of staff spoken with said that they had been shown how to use lifting equipment but had not attended manual handling training since starting at the home. They also confirmed that they had done their induction training and fire safety on the first day at work. Staff also confirmed that they are provided with infection control training but it could not be confirmed if this was up to date for all staff One member of staff said that they had been off sick when the training was last provided. Staff spoken with said that they had had an appraisal to discuss their progress, but do not generally have one to one supervision. Staff felt they were well supported by senior staff, that communication was good and they could approach senior staff with any concerns or questions. Staffing levels at Kingfisher House are sufficient to meet resident’s needs. Inspectors were informed by a senior member of staff that currently one member of staff had limited use of the English language and is unsafe to work with residents on a one to one basis until their English has improved. The acting manager confirmed that the member of staff in question was being rotad on as an extra to the staffing levels until their English improved. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 37, 38 Resident’s storage of records does not safeguard service users interests and rights. Residents can expect that Kingfisher House is run in their best interests, and the health, safety, and welfare of residents is promoted and protected. EVIDENCE: The Registered Manager of Kingfisher House has been promoted within the company, so leaving Kingfisher House with no permanent manager. A manager from another Four Seasons care home is undertaking current managerial responsibilities. The organisation is currently interviewing to fill this vacant post. Records are stored on a shelf in the corridor, allowing access to individual’s personal information to anyone visiting the home. Personal records should be stored in a secure place within the home. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 19 Residents spoken to all stated that they are happy in the home and feel their best interests are taken into account in the running of the home, and that they are safe. Corridors were free of obstructions; the home is well maintained and safe. There was evidence from the information provided in the pre inspection questionnaire and confirmed in records that equipment is routinely serviced and maintained. However as noted in the Environment Section of this report there is a need to ensure that sufficient equipment is available. Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 2 3 3 2 2 STAFFING Standard No Score 27 3 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x 2 2 Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9.3 Regulation 13.2 Requirement The Registered Person must ensure that the administration of medicines policy and procedure is adhered to. MAR sheets should be completed to confirm medication has been administered Fire doors must not be wedged open at any time. Residents personal records must be stored in a secure place There must be sufficient lighting provided in service users rooms. Staff employed must have the communication skills to support residents Timescale for action immediate 2. 3. 4. 5. 38.3 37 24 29.1 23. (4) (a) 17.(1).(b) 23 (2) (p) 19 (5) (b) immediate immediate Immediate Immediate 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. 3. Refer to Standard 12 36 38 Good Practice Recommendations An activities co-ordinator should be employed Staff training records should be kept up to date and in the home Aprons and disposable gloves should be readily available to staff working on both floors I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 22 Kingfisher House 4. 5. 38 15 A system for monitoring the availabiltiy of equipment should be introduced to ensure shortages are identified. Further staff training should be identified regarding helping service users while eating meals Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 5th Floor St Vincent House Cutler Street Ipswich IP1 1UQ 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 Kingfisher House I54 - I04 S24427 Kingfisher House V230290 050727 Stage 4.doc Version 1.40 Page 24 - 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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