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Inspection on 14/09/06 for Kingsfield Care Centre

Also see our care home review for Kingsfield Care Centre for more information

This inspection was carried out on 14th September 2006.

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

All service users spoken to during the visit were positive about the care they received. One service user said "I really like it here ... food is good ... people are good ... staff all very good." Similarly, all visitors spoken to during the visit were positive about Kingsfield. One visitor said "you could put [in the report] its first class ... the ambience is great." Another visitor cited the "cleanliness and staff" as the best things about the home. All visitors reported that the staff were welcoming and communicated well with them. They were confident about the care offered to their relatives. The home provides well maintained, clean and pleasant accommodation in single rooms. The staff team are supported to undertake appropriate training to improve their skills and knowledge.

What has improved since the last inspection?

The good quality of care experienced by service users has been maintained. Staffing levels at key points in the day have been improved for the benefit of service users.

What the care home could do better:

Kingsfield must ensure all staff rigorously follow the home`s procedure for the administration and recording of medication to minimise the risk to service users. To minimise any risk of cross infection, all staff must adhere to the home`s procedures to prevent any creams being shared between service users. Whilst a good start had been made to exploring and noting service users` `life history`, more detail would further improve the ability of staff to respond to the individuality of each service user. Better recording would enable the home to demonstrate that it had taken all reasonable steps to vet the staff who are working with the potentially vulnerable service users.

CARE HOMES FOR OLDER PEOPLE Kingsfield Union Road Ashton-under-Lyne Tameside OL6 9JF Lead Inspector Steve Chick Unannounced Inspection 14th September 2006 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kingsfield DS0000005573.V311451.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. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsfield Address Union Road Ashton-under-Lyne Tameside OL6 9JF 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) 0161 330 1853 Tameside Care Limited Rita Shockledge Care Home 52 Category(ies) of Dementia - over 65 years of age (48), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (48), Old age, not falling within any other category (52), Physical disability over 65 years of age (18), Sensory Impairment over 65 years of age (2) Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 52 OP; up to 48 DE (E); up to 48 MD (E); up to 18 PD (E); and up to 2 SI (E). 24th February 2006 Date of last inspection Brief Description of the Service: Kingsfield is a single storey, purpose built, detached property set in its own grounds. It offers accommodation for up to 52 older people, in single rooms. Kingsfield is near the town centre of Ashton under Lyne and, consequently, has good access to public transport facilities. There are also parking facilities in the vicinity. Kingsfield has two lounge/dining rooms and one small lounge, which is a dedicated smoking area, and a quiet room. The building also has a conservatory area off the main lounge and a patio area in the inner garden. Kingsfield is run by Tameside Care Limited, which also runs several other care homes in the area. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. For the purpose of this inspection three service users were interviewed in private, discussion also took place with two service users without the presence of staff. Five relatives of service users were also interviewed in private. Additionally, discussions took place with the deputy manager and two staff members were interviewed in private. The inspector also undertook a tour of the building and looked at a selection of service user and staff records, as well as other documentation, including staff rotas, medication records and the complaints log. This key inspection included an unannounced site visit to the home. All key standards were assessed. What the service does well: All service users spoken to during the visit were positive about the care they received. One service user said “I really like it here … food is good … people are good … staff all very good.” Similarly, all visitors spoken to during the visit were positive about Kingsfield. One visitor said “you could put [in the report] its first class … the ambience is great.” Another visitor cited the “cleanliness and staff” as the best things about the home. All visitors reported that the staff were welcoming and communicated well with them. They were confident about the care offered to their relatives. The home provides well maintained, clean and pleasant accommodation in single rooms. The staff team are supported to undertake appropriate training to improve their skills and knowledge. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 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. Kingsfield DS0000005573.V311451.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 Kingsfield DS0000005573.V311451.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6 Quality in this outcome area is good. Service users are only admitted to the home after an appropriate assessment to ensure the home can meet their needs. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: A selection of service users’ files was looked at. All had a copy of an assessment undertaken by an appropriate professional before the service user moved to the home. There was also documentary evidence that external assessments were complemented with the home’s own ‘pre-admission’ assessment. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 9 There was documentary evidence that the home considered its ability to meet the needs of any individual service user before admitting them. Kingsfield also confirmed their ability to met the assessed needs, in writing. In each file seen there was a signed copy of the home’s terms and conditions. Kingsfield does not offer intermediate care. Kingsfield DS0000005573.V311451.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. Service users have individual plans of care which are regularly reviewed to ensure they reflect current physical needs. Service users have access to appropriate community based medical services to ensure their health needs are met. The home’s procedures in connection with administration of medication are predominantly implemented to the benefit of the service users. Practices in the home promote the dignity of service users. This judgement has been made using available evidence, including a visit to the service. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 11 EVIDENCE: A selection of service users’ files was inspected. All had a written copy of a care plan. There was documentary evidence that the plan was reviewed at appropriate intervals and amended if necessary. There was documentary evidence that service users were involved in the care planning process. In one example seen, where the service user was unable to sign, a representative of theirs had done so on their behalf. Some files had a document recording the ‘life history’ of the service user. This is good practice which reinforces the individuality of each service user. Examples seen contained quite basic information and may benefit from a different format to record more information. Daily records were mostly minimally maintained. Staff who were interviewed reported that care plans were used as a tool for being aware of the service users’ needs. This was complemented by verbal handovers at each shift change and a communication book. Service users and visitors spoken to were complimentary about the care they received at Kingsfield. One service user said “I really like it here … [everything] has been very, very good, much better than sitting in your home on your own.” Visitors experienced good communication from the home and reported that the home was responsive to their views. One visitor also commented on how supportive staff had been to them over their feelings when their relative had first come to live at Kingsfield. There was documentary evidence that service users had appropriate access to the full range of medical and para medical services available in the community. Service users and relatives spoken to, were confident that appropriate medical support was arranged when necessary. Similarly, staff were confident that service users’ health needs were met and they received good support from the District Nurses. There was documentary evidence that service users were weighed regularly to ensure early identification of any significant weight gain or loss. The home has appropriate policies and procedures in connection with the administration of medication. These were not looked at during this visit. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 12 The home uses a pre-dispensed monitored dosage system to administer service users’ medication. Medication was seen to be appropriately and securely stored. The record of the temperature of the medication fridge, to ensure it is working effectively, had not been completed in the preceding few weeks. The temperature of the fridge at this visit was acceptable. Medication administration records presented as predominantly appropriately maintained. However, one example was seen where a medicine was documented as being given in one record, but not in another. This had occurred at a point when the service user’s prescription had just changed. Whilst only one error was seen in the selection of medication administration records looked at, any error in this area has the effect of discrediting the reliability of the other records. During the tour of the building, a tub of medicinal cream was seen in one bathroom. This did not have the name of a service user on it and staff spoken to were unable to identify to whom it belonged. The implication was that cream was being shared between service users. The deputy manager was clear that, if true, this was very poor practice and against the home’s policies and procedures. Observation and discussion with service users, visitors and staff indicated that service users were treated with respect, and that their dignity was maintained. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. Appropriate social contacts and activities are facilitated within the home to give service users the opportunity for social fulfilment. Visitors are welcome in the home to maintain community and family links for the benefit of service users. Service users are able to maximise their autonomy within the context of community living. The provision of food to maintain service users’ health and well being is good. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: Service users, visitors and staff were able to identify a range of social activities which are available for service users to participate in if they wish. These included activities within the home as well as outings. One visitor reported that their relative was happy with activities and had particularly enjoyed the Morris Dancers who had visited in the summer. One service user was aware of activities being available but said that she chose not to participate in them. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 14 During the visit staff were observed assisting a group of service users doing a jigsaw. The record of each service user’s life history, mentioned elsewhere in this report, would also serve to improve the home’s ability to respond to individuals’ social fulfilment. Service users spoken to confirmed that they had freedom of choice about when they got up and went to bed. Similarly, observation and discussion with service users confirmed their ability to use any of the communal facilities, or their own room whenever they chose. The deputy manager reported that a church choir visits the home on a monthly basis and Holy Communion is also available, monthly, within the home. Kingsfield has a written policy of encouraging visitors to the home. All visitors and service users who were asked confirmed that they were able to visit at any reasonable time. One visitor spoken to described the staff as “welcoming and friendly”. Another expressed the view that “People will go out of their way for you, all of them.” A ‘thank you’ card had been received on the day of this visit which noted their appreciation of being “always offered a cup of tea” on arrival at the home after their long journey. Records indicated that service users were able to maintain control over, for example, their financial affairs and medication (subject to an appropriate risk assessment). During the visit a meal was sampled. This was pleasantly presented and tasty. Service users spoken to were complimentary about the provision of food at Kingsfield. One visitor confirmed that their relative needed encouragement to eat and had put on weight in the short time they had been at the home. The deputy manager reported that, on one occasion, where a service user from an ethnic minority group was resident for a respite period, Kingsfield had discussed their dietary needs with the family and during their stay a local cultural centre had supported the home in the provision of appropriate food. Staff who were asked, expressed the view that appropriate food in ample quantities was provided in the home. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. Service users are confident that any complaint they may have would be dealt with appropriately. Service users are protected from abuse or exploitation by the home’s policies and practices. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: Kingsfield has an appropriate written complaints procedure which is made available to service users and other interested parties. The log of complaints presented as being appropriately maintained. Service users, visitors and staff who were asked, were confident that any concern would be responded to appropriately by staff and management in the home. One service user was not sure if they would actually make a complaint, but was very positive about the care they received. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 16 Visitors were able to cite relatively minor issues which they had felt needed to be raised with the home. In all cases, they reported that the home responded quickly and helpfully. One visitor said she was “very pleased” with the outcome following her action in pointing out a concern. Kingsfield has appropriate policies and procedures in connection with the protection of vulnerable adults. These were not looked at during this visit. Staff who were interviewed demonstrated an understanding of the need to be vigilant about the possibility of abuse, and of appropriate action to take. This included the ‘whistle blowing’ procedure. All service users spoken to expressed the view that they were safe at Kingsfield. Visitors and staff also expressed the view that service users were safe. Visitors who were asked, confirmed that their observation of staff’s interaction with other service users during their visits indicated appropriate behaviour and relationships were maintained. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24 and 26. Quality in this outcome area is good. The home is appropriately maintained, decorated and cleaned to enable service users to live in a pleasant, safe and hygienic environment. Suitable toilet and bathing facilities are available to enable service users to maintain their personal hygiene in a dignified manner. This judgement has been made using available evidence, including a visit to the service. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 18 EVIDENCE: During this unannounced visit to the home a tour of the building was undertaken. This included communal areas and a selection of service users’ bedrooms. There were several communal areas where service users could spend their time, or they could access their rooms when they chose. The building presented as appropriately maintained and decorated throughout. No items requiring remedial maintenance were identified. Since the previous visit, the foyer had been refurbished. The deputy manager reported that work on the refurbishment of ‘C’ lounge was planned to start the following week. Service users’ bedrooms showed clear signs of personalisation. The deputy manager confirmed that, subject to space and health and safety requirements, service users were encouraged to bring their own possessions into the home. The home presented as being clean and tidy throughout. This was confirmed as the usual state of the home by service users, visitors and staff spoken to. One visitor described the home as “beautifully clean” and another said the home was “always nice and clean”. One service user said they had a “very nice room” which was always kept clean and tidy. Kingsfield has appropriate toilet and bathing facilities, including adaptations and aids for service users with restricted mobility. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. Minimum staffing levels are maintained to ensure the health and safety of service users. The numbers and skill mix of staff on duty promotes the independence and well being of service users. Recruitment procedures are appropriately applied to minimise the risk to service users of inappropriate staff being employed. This judgement has been made using available evidence, including a visit to the service. EVIDENCE: The staff rota for the week beginning 4th September 2006 was examined. This demonstrated that staffing was predominantly maintained at a level of between five and six carers between 08:00 and 20:00, four carers between 20:00 and 22:00 and three carers between 22:00 and 08:00. There were many occasions throughout the week when staffing levels were higher than this. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 20 The deputy manager reported that difficulties identified at previous visits in connection with staffing levels in the evening had now been resolved. Examination of the staff rota confirmed this to be true. Additionally, the home employed cooks, domestic staff and a handyman. The manager’s hours were in addition to those identified above. The issue identified at the previous inspection, relating to night staff’s uncertainty regarding emergency cover during the night in circumstances where, for example, a staff member needs to leave the home to escort a service user to hospital, had been satisfactorily resolved. Appropriate written guidance was seen in the night staff’s file. It was reported by the deputy manager and noted on the training ‘matrix’ in the office that 18 of the 24 care staff held an appropriate NVQ. A random selection of these staff was selected and documentary evidence of their qualification was seen. A selection of records relating to newly recruited staff was seen. These records, and discussion with the deputy manager, indicated that appropriate vetting procedures had been followed. Examples were seen in relation to two referees when a written record of the explanation as to why those referees had been accepted in preference to other potential referees would have made the vetting more transparent. Similarly, a written explanation of why a different home in the Meridian Healthcare group had undertaken the vetting of a Kingsfield member of staff would have assisted in clarifying accountability. Staff who were interviewed confirmed that the organisation continued to offer an appropriate range of training opportunities. This was also evident from training records maintained in the home. Staff interviewed also confirmed the organisation’s policy of ensuring all new staff undergo a period of induction was always implemented. Service users and visitors who were spoken to, were complimentary about the staff’s attitude. One service user said “I get on well with the carers … [I] like all the staff, they pull my leg.” Another service user described the staff as “all very good” and two visitors described the staff as “very helpful”. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. The manager is appropriately experienced and qualified to run a care home for the benefit of service users. Quality Audit processes provide a framework to further improve services for the service users. Service users’ financial interests are protected by the home’s procedures and practices. Service users and staff are protected by the implementation of the home’s health and safety procedures. This judgement has been made using available evidence, including a visit to the service. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager at Kingsfield was on annual leave at the time of this unannounced visit. However, previous contact with her has provided evidence that she has ample experience in a managerial position, together with the necessary skills and qualifications to undertake her role appropriately. Meridian Healthcare Ltd has established appropriate and clear lines of accountability between the home and the rest of the organisation. The home has structured Quality Audit and Quality Monitoring procedures, in addition to the less formal means of establishing the views of service users. The report produced in August 2006 of the Quality Audit undertaken by the company contained neither the manager’s comments on the outcome, nor any action plan on how issues identified for improvement would be taken forward. The deputy manager reported that issues had, in fact, been addressed with service users and was able to offer evidence of this with the minutes of a There was also meeting with service users held on 18th August 2006. documentary evidence of service users’ meetings held on three previous occasions in 2006, which was indicative of the home’s continued efforts to involve service users. A selection of records relating to money held by Kingsfield on behalf of service users was looked at. The records presented as being appropriately maintained to safeguard the interests of the service users. There was also documentary evidence that these records were periodically audited by the home’s manager, which is good practice. It was reported by the deputy manager that all staff receive at least basic training (including periodic refresher courses) in issues related to health and safety, such as moving and handling and food hygiene. This was confirmed in discussion with staff and examination of a selection of training records. Observation and discussion with staff confirmed that appropriate equipment, such as disposable gloves and aprons, were always available to minimise the risk of cross-infection. In August 2006 there had been a fire at the home. The home had reported the incident to the Commission for Social Care Inspection. That report indicated that appropriate action had been taken and that no service user was injured. During this site visit a member of staff who was on duty at the time of the fire confirmed that staff had responded appropriately. Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 23 Following this fire, Meridian Healthcare Ltd and the Greater Manchester Fire and Rescue Service have been in correspondence in connection with the suitability of equipment to prevent the spread of smoke and fire. At the time of writing this report, that correspondence is continuing. The deputy manager reported that all necessary maintenance contracts for equipment in the home were being maintained. A selection of records relating to the maintenance of equipment, including fire detection and alarm, was looked at and presented as being appropriately maintained. Kingsfield DS0000005573.V311451.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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 3 3 3 3 3 X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Kingsfield DS0000005573.V311451.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 OP9 Regulation 13 Requirement The registered person must ensure that medication procedures are rigorously followed, particularly in connection with the maintenance of accurate medication administration records. Timescale for action 01/10/06 Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 26 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 OP7 Good Practice Recommendations The registered person should ensure that the format for recording the ‘life history’ of each service user enables more depth of information to be recorded, to assist in informing staff responses to that individual. The registered person should ensure that the temperature of the fridge used for the storage of medication is recorded on a daily basis. The registered person must ensure that no topical creams are shared between service users. The registered person should ensure that there is a written record to explain any anomalies in the recruitment process for new staff. The registered person should ensure that the report of the Quality Audit includes an action plan to indicate how the home is intending to improve its service. 2 3 4 5 OP9 OP9 OP29 OP33 Kingsfield DS0000005573.V311451.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Kingsfield DS0000005573.V311451.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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