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Inspection on 15/04/08 for Kingsdowne Residential Home

Also see our care home review for Kingsdowne Residential Home for more information

This inspection was carried out on 15th April 2008.

CSCI found this care home to be providing an Adequate service.

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

The home consistently provides an excellent environment that is clean and homely, attractively decorated and well maintained. People who come to live in the home, first have their needs assessed to make sure that the home is suitable for them and they can bring their personal possessions with them. People who fund their care will have a contract that shows what services they are paying for. The staff make sure that if someone is unwell, they will be referred for treatment promptly and the home has good systems to ensure that medication is stored safely so that residents` well being is protected. If anyone has any concerns about their care, these will be taken seriously and acted upon and residents are further safeguarded by staff being trained and aware of what constitutes abuse. There is a stable group of staff who have worked at the home for a long time. This ensures that the staff are familiar with the needs of the people who live in the home and provides a consistent approach, which reassures residents. The manager has been in post for a long time and involves the residents in the way she runs the home.

What has improved since the last inspection?

The home ensures that people who fund their own care are given a contract of the terms and conditions of the service for all residents will say if it is for single or double room. The home has improved their recording of controlled drugs so that all medication is accounted for.

What the care home could do better:

All residents, particularly those who are recently admitted, must have a written care plan that accurately reflects their current needs and all the staff need to be trained to be competent in writing care plans. It is important that staff always witness residents taking their medication to prevent mistakes being made which could affect the resident`s wellbeing. All care staff must have at least six formal supervisions a year with their line manager to monitor their performance and to support them in their role as carers.

CARE HOMES FOR OLDER PEOPLE Kingsdowne Residential Home 37 Dury Road Hadley Green Barnet Hertfordshire EN5 5PU Lead Inspector Tom McKervey Key Unannounced Inspection 15th April 2008 09:30 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 Kingsdowne Residential Home DS0000010459.V361356.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. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsdowne Residential Home Address 37 Dury Road Hadley Green Barnet Hertfordshire EN5 5PU 020 8449 0675 020 8440 8220 jan.higham@kingsdowne.co.uk 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) The Kingsdowne Society Mrs Janette Maria Higham Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2006 Brief Description of the Service: Kingsdowne Residential Home is a registered care home for eighteen older people of either gender. The home is situated in the Hadley Green area of Barnet, within approximately a ten-minute walk to shops and other amenities in Barnet High Street. The accommodation comprises of sixteen single bedrooms and one double bedroom. The home has large dining and lounge areas and a conservatory. There are extensive grounds, with a car park at the front of the property. There are also very attractive rear and side gardens, which are accessible via a ramp for people who use wheelchairs. There are adequate toilet and bathing facilities in the home. There is a large kitchen and laundry room, and the staff room and main office are also situated on the ground floor. A passenger lift makes the first floor accessible. The staff turnover is very low and several staff have worked at the home for a number of years. The manager, Ms Janette Maria Higham, has been in post for many years. The aim of the home is To meet residents’ expectations and achieve the greatest quality of life that is possible, whilst encouraging residents to maintain their independence. The fees for the service are £539 per week. Following Inspecting for Better Lives, the provider must make information available about the service, including inspection reports, to service users and other stakeholders. Kingsdowne Residential Home DS0000010459.V361356.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 an unannounced inspection. The process took place over a period of six hours and was carried out as part of the Commission’s inspection programme to check compliance with the key standards. This service was rated as excellent, (3 stars) at the last key inspection in April 2006 and therefore, did not require an inspection in 2007. Instead, in March 2008, the Commission carried out a review of the service by looking at all the information we had received about the home, including reports from Trustees who visit the home monthly to monitor the service. Also, as part of the service review, we received back ten completed questionnaires that we sent out, from the people who live in the home, giving us their views about the service they received. Another important document we received was the Annual Quality Assurance Audit, (AQAA), which is a self-assessment by the management of the home, which focuses on how well outcomes are being met for people who use the service. It also gives some numerical information about the service. After reviewing all this information, we concluded that the home continued to be rated as excellent. I have referred to the AQAA as evidence of some findings, in various sections in this report. It is disappointing to report that at this inspection, some key standards were not met, which has resulted in the service’s quality rating being downgraded. At the time of the inspection, there were sixteen people living in the home and there was one vacancy. At present, a double room is designated as a single. The home is considering making this permanent, which will reduce the total number of places to seventeen. If the home decides to confirm this, they must inform the Commission in writing and a new registration certificate will be issued to reflect this. The inspection included a tour of the premises and speaking to the manager. Ten individual residents and several staff were interviewed about their experiences of living and working in the home. There were no visitors during the inspection. Residents’ and staff records, and documents pertaining to the running of the home were also examined. What the service does well: The home consistently provides an excellent environment that is clean and homely, attractively decorated and well maintained. People who come to live in the home, first have their needs assessed to make sure that the home is suitable for them and they can bring their personal possessions with them. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 6 People who fund their care will have a contract that shows what services they are paying for. The staff make sure that if someone is unwell, they will be referred for treatment promptly and the home has good systems to ensure that medication is stored safely so that residents’ well being is protected. If anyone has any concerns about their care, these will be taken seriously and acted upon and residents are further safeguarded by staff being trained and aware of what constitutes abuse. There is a stable group of staff who have worked at the home for a long time. This ensures that the staff are familiar with the needs of the people who live in the home and provides a consistent approach, which reassures residents. The manager has been in post for a long time and involves the residents in the way she runs the home. 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. The summary of this inspection report can be made available in other formats on request. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service and looking at residents’ documents. People who come to live in the home can be assured that their contracts provide full details about what is covered by the fees for the service and their needs will be assessed to make sure that the home is suitable for them. EVIDENCE: At the time of this inspection, seventeen people were living at the home and there was one vacancy. I examined the case records of four people who were recently admitted, and one other. All four new residents were privately funding their care and all had signed contracts that included the terms and conditions of the service and the fees charged. There is one double room available for couples but the manager said that this is also used as a single room when necessary. Should the board of Trustees Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 9 decide to reduce the number of places permanently, they must inform the Commission so that a new registration certificate is issued to reflect this. The case files contained preadmission assessments. The admission form includes details about people’s culture and ethnicity and whether they practise their religion. The assessments indicated that the home was appropriate to meet people’s needs. All areas of the home are accessible to anyone who has mobility problems. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including looking at residents’ care plans and health records. The people who live in the home can be confident that staff make sure that they receive prompt health care treatment and intervention. There are significant gaps of information in the care plans about some residents’ needs, which could have a detrimental effect on the care they receive. This has resulted in this outcome being downgraded to “adequate”. Medication is stored safely, but more care must be taken when administering medicines to ensure that residents take them to maintain their wellbeing and someone else does not take them by mistake. EVIDENCE: I examined five care plans in detail, four of which belonged to people who had been admitted within the last two months. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 11 Two care plans were fully written up and included assessments, goals of care and guidelines for staff about how to meet the residents’ needs. There were written assessments for example, about mobility, nutrition and pressure areas. These two care plans had been reviewed by the manager about six weeks after the person’s admission to the home. However, the care plans of the three other people who were admitted were poor, and these people had been living in the home for at least three weeks or more. For example, one of these care plans stated, “X can do everything for themselves” without any other comments recorded. This resident did not have any written assessments of their needs and the other two care plans were only partly completed and missed significant areas of assessment. This could lead to staff not being fully aware of residents’ needs and how best to support them. The manager explained that the staff responsible, had difficulty in understanding and compiling care plans, (even though they were identified as the resident’s key worker). I have made requirements to ensure that that all residents have an up to date care plan that ensures that all their needs are being addressed and that all staff who are allocated as key workers, are trained and are competent to write care plans. However, I attended the staff handover and listened to the discussion about the residents’ care. I also observed how the staff supported people and I was satisfied that they were knowledgeable about the residents and were very caring in their approach to them. There were records in the case files to show that residents are registered with a G.P and the district nurse visits regularly to attend to wounds and administer insulin. At the time of this inspection, no-one was in hospital or in poor health and there were no pressure ulcers. Other healthcare appointments were recorded, for example out-patient departments, opticians, dentists and chiropodists. There were charts to monitor residents who had a history of falls, and their weight and blood pressure were also being monitored. I was satisfied that medication was safely stored and staff signed when they administered medicines. Temazepam tablets, (which are controlled drugs), were properly accounted for and were stored in a separate controlled drug cupboard. I was concerned to see staff leaving dose of medication on the dining table for a resident to take themselves when they finished eating. This is not safe practice. Staff should always witness residents taking their medication to ensure that they don’t forget to take it, or someone else takes it by mistake. I have made a requirement about this issue. I spoke to ten residents, of all of whom spoke highly of the staff and the care they received. They said that the staff were very caring and attentive when providing personal care, which was done in a discreet and dignified manner. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 12 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): All these standards were assessed. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live in the home say they are able to choose how they spend their time. Appropriate activities are provided but staff should be more diligent in recording these. There is frequent contact with friends and relatives and the residents speak highly of the meals provided which are nutritious and varied. EVIDENCE: I spoke to ten people who live in the home. They described how they spent their day and some said they joined in the various organised activities, while others preferred to “do their own thing” like reading or listening to the radio in their room. Several residents were observed reading books and newspapers. In the good weather, people spend time in the large attractive gardens. Examples of organised activities were included in the AQAA, for example, weekly arts and crafts and keep-fit sessions, and once a month an outside entertainer visits the home. I noted however, that staff do not always record Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 13 when residents partake in these activities and I recommend that they do so as evidence that all residents partake in stimulating activities of their choice. The AQAA also states that the home purchased a freeview digital box to provide more choice of television programmes for the residents. All the current residents are of white/British origin. People’s religious and cultural backgrounds are documented on admission, (but see the comments about care plans above). Religious services are held regularly in the home. Staff have attended training on equal opportunities. The residents described the choices they made about their lives, including when to rise and go to bed and about what they wanted to eat. They also choose what activities they wish to partake in. One person said, “We are encouraged to join-in but no-one makes you do anything you don’t want to” There were no visitors to the home during the inspection, but the visitor’s book showed that there are frequent visits by friends and relatives at various times of the day and evening. Residents can receive visitors in their rooms and/or the many other private areas in the home. The people who live in the home spoke highly of the staff; for example, ”They are very good. Nothing is too much trouble”. “ The staff are very attentive, you don’t even need to ask sometimes”. The dining room is quite spacious and provides an attractive area to enjoy meals. The menus showed a good variety of wholesome food and the cook showed me how special diets are catered for. The cook comes round and asks residents what they would like to eat and provides alternatives to the menu as necessary. They also said they could have hot or cold drinks and snacks at any time. Records are kept of the temperatures of the fridges and freezers and of the food actually eaten by the residents. I joined three residents for lunch. The meal consisted of meat and two vegetables and gravy and there was a choice of ice cream or sponge and custard for dessert, all of which tasted very good. The meal was also hot and well presented. I observed a resident being supported by a member of staff. The staff sat beside the person and engaged them in conversation during the meal, which was unhurried. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including speaking to residents and staff in the home. The people who live in the home can be confident that their concerns are taken seriously and that the staff are trained and are aware of how to protect residents from abuse. EVIDENCE: The residents that I spoke to, said they were very satisfied with their care, and had no concerns or complaints. They said they were confident that complaints would be addressed promptly. The complaints procedure is displayed on the notice board in the residents’ dining room, and includes contact details for the Commission for Social Care Inspection, should anyone wish to raise concerns directly. As part of the home’s service review in March this year, the Commission for Social Care Inspection sent questionnaires to the residents, ten of which were returned. The comments from the residents were very positive about their experience of living in the home. The complaints log had one entry since the last inspection. This matter was investigated by the manager and was found not to be substantiated. I was satisfied that the procedure had been followed properly. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 15 During my discussions with staff and residents, an allegation was made to me that some night staff were intolerant of some residents who used the call bell to summon help. The manager was surprised when I spoke to her about this but she said she would investigate this matter and inform me of the outcome. The majority of staff have attended training in the subject of protection of vulnerable people from abuse, and training was booked for those who had not done so yet. The staff who I spoke to, were knowledgeable about their responsibilities regarding reporting suspected abuse. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 24, 25 & 26 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including visiting all areas of the home and examining records. People can be confident that they will be comfortable in a safe, well maintained home and they are able to bring their personal possessions with them. EVIDENCE: I carried out a tour of the home, including several bedrooms. The overall appearance of the home is very attractive and the grounds are well maintained. All areas of the home are easily accessible, including the gardens, where a ramp is provided for wheelchair users. Grab rails are well positioned in toilets and bathrooms for people with problems with mobility, and there are several hoists available. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 17 In the AQAA, the manager states that the home has purchased new conservatory blinds, new bed linen and commodes, and a whole new fire alarm system in the past year. Staff have been trained in infection control and are provided with disposable gloves and aprons for carrying out personal care. The residents can summon help with call alarms that they can wear around the neck. I saw records of weekly fire alarm tests and regular fire drills. The service records of hoists and the lift were available for inspection. The communal lounges and dining areas are pleasant and bright with comfortable domestic-style furniture. There is a well equipped kitchen and laundry. There is a passenger lift to the upstairs bedrooms, which are tastefully decorated and there were plenty of personal possessions and family photographs on display in the rooms. A full-time maintenance person ensures that repairs are carried out promptly and there is a dedicated team of cleaners who keep the home very clean and tidy. The home smelled fresh and pleasant at the time of the inspection. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 18 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): All these standards were assessed. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live in the home can be confident that sufficient numbers of staff are available to meet their needs and their welfare and best interests are safeguarded by safe recruitment procedures. EVIDENCE: I examined the duty rota, which gave an accurate record of the staff actually on duty during the inspection. The normal staffing levels are; four care staff on the early shift and three on the afternoon/evening. There are two staff on waking duty at night. The staff to whom I spoke, said they were satisfied with the level of staffing available. The residents also confirmed that there was always sufficient staff available to meet their needs. This staff group consists of a deputy manager, three senior carers and thirteen care staff. The home also employs a maintenance person, an administrator, and cleaning and cooking staff. The team has been together for a considerable time, and at the time of the inspection, there were no staff vacancies. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 19 Two staff who had left recently, were replaced by two new people whose records I looked at. I was satisfied that proper recruitment procedures had been followed including Criminal Records Bureau checks and references. The staff records showed that they had undertaken a lot of training, including mandatory health and safety subjects. Two people, including the manager, had attained a certificate in dementia care from Barnet College. Eight care staff have attained National Vocational Qualifications at level 2 or above, and five are in the process of completing them. This meets the required standard of at least 50 of staff having this qualification. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38, People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a discussion with the manger and staff and examining records. The home is well managed by an experienced and skilled manager, who provides clear leadership for the staff sensitively and efficiently, but some staff do not have regular supervision which could lead to poor practice issues not being addressed. People who live in the home can be confident that the home’s installations and equipment are regularly serviced to ensure their health and safety. EVIDENCE: The registered manager holds a City and Guilds Advanced Management in Care qualification and has been running the home for many years. Last year, she Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 21 attained a certificate in dementia care, awarded by Barnet College. The manager is responsible to a board of trustees who carry out monthly monitoring visits in the home. Reports of their findings are sent each month to the Commission. The manager is highly regarded by the staff who said that she was very sensitive in her dealings with them and sets high standards for the care of the residents which staff are expected to achieve. The manager sent an AQAA to the Commission in October last year about the service. This document, along with completed questionnaires from residents, was used as part of the Commission’s service review. The manager said she planned to carry out an audit the service in June this year, but acknowledged that some people who live in the home may be reluctant to complete another questionnaire so soon after the last one. I noted that meetings are held regularly with staff and residents to discuss the running of the home, at which people are able to air their views. This was confirmed by the residents and the staff I spoke to. The home has a good record of responding to and complying with, any requirements and recommendations that were made at previous inspections. In discussion with the staff, I learned that some of them have had supervision sessions with their line managers, but this was patchy and not all staff are receiving this. This was acknowledged by the manager as an area that the home needs to improve upon, and I have made a requirement about this issue in this report. There were current service records available for fire, electric, water and gas installations and an employer’s liability certificate was on display. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 22 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 X 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 4 3 X 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 3 Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement All residents must have a written care plan that accurately reflects their current needs. Staff must ensure that they witness residents taking their medication to prevent mistakes being made which could affect the resident’s wellbeing. All care staff must have at least six formal supervisions a year to support them in their role as carers. All staff who are responsible for compiling care plans must be trained and competent to do so. Timescale for action 30/04/08 2. OP9 13(2) 29/04/08 3. OP36 18(2) 31/05/08 4. OP30 18(1)(c) 31/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 24 1 OP12 Staff should keep a record in residents’ files of social and leisure activities that they partake in as evidence of their choice of stimulating activities. Kingsdowne Residential Home DS0000010459.V361356.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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. 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