Inspection on 09/10/06 for Kingsley House Nursing Home

This inspection was carried out on 9th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kingsley House Nursing Home 01/03/06

Kingsley House Nursing Home 30/08/05

Kingsley House Nursing Home 30/03/05

Kingsley House Nursing Home 18/11/04

Kingsley House Nursing Home 30/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Kingsley House Nursing Home Gumstool Hill Tetbury Glos GL8 8DG Lead Inspector Mrs Janet Griffiths Key Unannounced Inspection 9th October 2006 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 Kingsley House Nursing Home DS0000016486.V309354.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. Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsley House Nursing Home Address Gumstool Hill Tetbury Glos GL8 8DG 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) 01666 503333 01666 503318 The Cotswold Nursing Home Company Limited Mrs Barbara Jean Harpwood Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability (1) of places Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named Service User under 65 years of age Date of last inspection 1st March 2006 Brief Description of the Service: Kingsley House is a care home providing nursing care for thirty-three older people. The property is an historic eighteenth century building, which has been converted and adapted for its current purpose. Service users accommodation is provided on four floors, all of which are accessible by stairs and shaft lifts. A large number of residents are accommodated in shared rooms, with thirteen single rooms available. Some rooms provide en-suite facilities, or there are communal bathrooms that provide assisted bathing facilities and toilet facilities conveniently situated around the home. Each room has its own wash hand basin. Large lounges are situated on the first and ground floors, and a dining room and conservatory are also available on the ground floor. Information about the service to include CSCI reports is made available by the provider to prospective service users through the homes’ Statement of Purpose and Service Users Guide. At the time of inspection the fees are £525 -£650 per week. Additional charges are made for hairdressing £18.00, toiletries, chiropody £11.00, newspapers at cost and transport (occasional hospital visits) 70 pence per mile. Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced key inspection commenced on one day in October 2006, with the site visit that took place over 6.30 hours and was carried out by one inspector. During this time the inspector spoke with some of the residents to include those who had been admitted since the last inspection and staff working in the home, to include qualified and care staff, domestic, catering, laundry and administrative staff. The manager was present throughout the day. Four residents’ files were looked at in detail. Surveys were left with some service users, and with the administrator and the manager to hand out to relatives and to be completed with the residents where possible. Once returned, the results of the surveys will be collated and the information used in this or a later report. No relatives were spoken with on this occasion although staff were observed during the day dealing very sensitively with a bereaved relative and a good friend of a recently deceased resident. What the service does well: The home has a friendly, welcoming atmosphere and is well maintained and comfortably furnished. The residents spoken with confirmed that they are well cared for, the staff are kind and friendly and that they have excellent food provided. The staff are well trained, appear competent in, and appear to enjoy their work. All spoken with were very helpful and seemed to understand the needs of each resident and how to meet them. Kingsley House Nursing Home DS0000016486.V309354.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. Kingsley House Nursing Home DS0000016486.V309354.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 Kingsley House Nursing Home DS0000016486.V309354.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): 3; 6 not applicable Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. The admission process is well managed and with full pre-admission assessments the home ensures that it is able to meet the needs of each service user. EVIDENCE: The home had admitted four new service users since the last inspection. This included one on respite care who was due for discharge the following day. Pre admission records were seen for each service user and from these the home was able to determine that they were able to meet the needs of these residents. Several had been admitted for respite care initially but because of changing circumstances had decided to stay. Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 9 One confirmed that the manager had visited him prior to admission and another said that his daughter had chosen the home for him, as he lived some miles away and wished to be closer to his family. All confirmed that they had settled in well, one saying that personal items such as pictures brought from home were helping him to feel more ‘at home’ and another said that although he wouldn’t have chosen to come into permanent care if circumstances were different, he felt quite happy now he was used to the home. All said how kind the staff were and appeared to have a good rapport with them, and all felt that their needs were being met. There is no intermediate care provided at this home. Kingsley House Nursing Home DS0000016486.V309354.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): 7,8,9,10 & 11 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. The care planning systems in place provides the staff with the information they require to care for all the residents’ needs. Service users are protected by the home’s policies and procedures for dealing with medicines. Service users health needs are fully met. Residents are treated with courtesy and respect. Residents are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. EVIDENCE: Care records of four service users were selected and examined in detail. This included medication records. All had full assessments completed to include moving and handling, pressure sore and any other risk assessment identified as necessary. Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 11 From the assessment appropriate care was planned and the care plans seen reflected the current needs of the service users. Night care plans were also completed. All had regular reviews completed with the service users/their relatives but they had not actually signed to confirm this. Other records include a social history form which gives a useful insight into residents lives prior to admission; a record of doctor and other medical professionals visits confirms that where problems are identified, advice is sought and appropriate action taken. Reference to among others, the district nurse, speech and language therapist and community psychiatric nurse, were seen. Residents also spoke of visits from the optician, chiropodist and hospital appointments they had attended or were due to attend. A record is kept in the form of wound charts for anyone with any wounds that require attention. These range from minor skin flaps, to leg ulcers and pressure sores of varying degrees. Photographs in some instances help to monitor the wound healing process and all wound charts seen show appropriate action taken and in most cases good response to the treatments given. Variable height beds, pressure relieving mattresses and cushions and specially adapted wheelchairs were seen in use where required. Some bed rails were also in use with protective bumper pads and consent forms for their use. Turn charts and fluid charts were also in use and staff were observed ensuring that residents were able to receive regular fluids. Catheter care was also noted. The home has a robust medication procedure in place. All the medication records were seen and were well maintained. Pain assessment forms were also seen in place for some residents. Printed medication administration records are provided with the blister packs of medications from the dispensing pharmacy. Storage arrangements were in place and satisfactory. The dispensing pharmacy carries out 3-monthly audits. They have a good working relationship with the home and provide information/advice where required. It was noted that in one resident’s room were four pots of various creams, dispensed for different service users with the name crossed out and another put on. Some of these creams had also been dispensed many months before; one was dated October 2005 and another August 2004. The resident apparently using these creams was prescribed for three of them but medicines prescribed for one person must not be used for another and once open expiry dates are limited. This was reported to the manager to investigate. This practice must cease. Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 12 The home has a number of shared rooms, but the privacy of the residents is maintained when personal care is carried out, personal possessions are clearly identified and each resident has their own personal storage space. Everyone is asked on admission whether they wish to share or not and if a shared room was the only one available for a prospective resident who did not wish to share then they would be given the choice to look for alternative accommodation. The manager makes every effort to ensure that the room provided for each resident is suitable for their needs. One resident spoken with who shares a room on the top floor said that although he and his companion don’t speak a great deal because of hearing disabilities, he feels more comfortable knowing there is someone else in the room with him. Last year the home took part in a pilot programme called the ‘End of Life Initiative’, run by the Avon, Gloucestershire and Wiltshire strategic health authority. The aim was to offer all adults in the home, nearing the end of their life the same high quality palliative care, enabling them to chose where they wish to die, for example in the home or transferred to hospital. One action plan that the group developed was to hold a thanksgiving and celebration service followed by a tea, in memory of all the residents who had died over the past year. The first was held on 6/2/06. Since this pilot was completed the home has introduced a number of specific care plans related to end of life, pain control and emotional support and as their expertise in this very important period of a residents life has become known more terminally ill residents have been referred to the home. One carer spoken with said that the programme has made her much more aware of the needs of the dying and the support to the families and as a resident had died a few hours prior to the inspection, staff were observed dealing very compassionately with relatives and friends who visited. Kingsley House Nursing Home DS0000016486.V309354.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 & 15 Quality is this outcome is good. This judgement has been made using available evidence including a visit to this service. Residents experience as stimulating and varied a life as they wish at the home should they choose to participate in the activities and social events available and all are helped to exercise choice and control over their lives. Visitors and community links are always encouraged. Service users receive a wholesome, appealing and balanced diet. EVIDENCE: The home’s activities organiser has recently left and a new one is to be appointed. In the meantime care staff ensure that some activities are offered to the residents at least twice a week. On the day of inspection none of the residents asked wished to participate in organised activities. Entertainment is organised monthly and recent outings organised have been to the Cotswold Wildlife Park, local garden centres for coffee, an organic sheep farm owned by a relative of one resident, Horse World and the Willow Trust canal trip. Photographs are displayed of some of these events. The next one advertised on the notice board is for Bonfire Night. A meeting of ‘The Friends Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 14 of Kingsley’ is also due soon to discuss future events and outings to include the Christmas arrangements. Monthly communion is also held at the home and the hairdresser visits each week. Those residents spoken with confirmed that they also have the choice of how and where they spend their days with some preferring to remain in their rooms to read, watch television or listen to music whilst others enjoy sitting together in one of the lounges and meeting for lunch. Two residents were reading and listening to music during the inspection and discussed the books they were reading. One also had a huge supply of videos and DVD’s his family had brought in for him and he talked about the pictures he had on his walls. Another talked about his love of fast cars. Some residents go out with their families and one was taken out during the inspection. A varied and appetising menu is in place and was seen during the inspection. In fact it was reported that one resident on respite care had responded so well to the meals during her stay, regaining her appetite which was previously very poor, that the relatives had requested a menu to take home. Everyone spoken with praised the quality and quantity of the food provided and the meal being prepared on this occasion looked and smelt very appetising. Homemade cake is offered each afternoon as well as fresh fruit salad for those who would like it and homemade soup and light meals and snacks provided for the evening meal. Snacks are always available on request throughout the night. Soft and pureed diets were also seen and were well presented and assistance was being offered in a discreet manner. One resident spoken with said that he had a soft diet, which was easier to manage and it always tasted nice. Food supplements are also available where a need has been identified. The kitchen was briefly visited on this occasion during lunchtime preparation and appeared clean and well organised. Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: The home has a complaints procedure, which was last reviewed in April 2006. A copy of this is included in the Service Users Guide that has been given to each service user/ their representative on admission. It was reported that the home has not received any complaints since the last inspection and CSCI have also not received any. The manager has an ‘open door ‘ policy and a very good rapport with all the families of the residents. Any concerns would be brought to her and immediate action taken so it is a rare event to receive complaints. The home also has an adult protection and abuse policy to include whistle blowing, last reviewed in April 2006. All new staff are instructed on this as part of the induction programme and it is also part of NVQ and adaptation training. Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 16 It was noted in files of new staff, which were examined that Protection Of Vulnerable adult training had been completed and was confirmed by certification. Training was provided in May and October last year and more training is booked for November 2006. Kingsley House Nursing Home DS0000016486.V309354.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 & 26 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing residents with an attractive and homely place to live. Good standards of cleanliness and hygiene are maintained. EVIDENCE: A tour of the home took place during the inspection with all communal areas, to include bathrooms and toilets inspected. However, not all rooms were visited on this occasion. All areas of the home seen were of a high standard of cleanliness and there were no obvious offensive odours. The cleaning staff were complimented on the cleanliness of the home. Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 18 All areas appeared to be well maintained with just a few areas of wear and tear visible but these had been identified and were being dealt with. All areas appeared to be well furnished and lounges and the dining room and conservatory comfortably furnished. Several rooms visited had been pleasantly personalised by items of furniture from resident’s own homes, photographs, pictures and ornaments. A repair and maintenance record was provided to show maintenance work identified and when it was completed. It was noted that several waste bins in bathrooms and toilets were without lids. This was discussed and new bins are being ordered. Plans have been drawn up for an extension to be built which will create more en suite bedrooms, a new laundry and increased space in the conservatory. These were seen and are currently awaiting planning permission. Kingsley House Nursing Home DS0000016486.V309354.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 7 30 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. Staff at the home are well trained and supported and employed in sufficient numbers to meet the residents needs. Robust procedures for the recruitment of staff are in place to provide safeguards and offer protection to people living in the home. EVIDENCE: Rotas were seen and also provided with the pre-inspection questionnaire. The home had 28 residents at the time of inspection and on-duty was the manager from 8 am to 5 pm, one RGN who has just completed adaptation and received her Personal Identification Number (PIN) and five care staff during the morning, two registered nurses and three care staff during the afternoon and two registered nurses and four care staff during the evening. The home on this occasion appeared to have sufficient staff to meet the needs of the residents who also confirmed this. Care needs are under constant review to ensure that adequate staffing levels are in place. The home does appear to have a large number of heavily dependent residents at present. Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 20 There are currently nine care staff with NVQ level 2 or above that equates to 64 . There are plans for three overseas staff to commence NVQ 3 and the home has applied for those under 25 years old to commence the Modern Apprenticeship. All new staff complete a full induction programme. A new programme called ‘Guidance for New Workers’ Common Induction Standards produced by Skills for Care is currently being introduced. In addition to this two staff have just completed adaptation and received their PINs. Six adaptation nurses worked as care assistants for 3 months before starting their training and continued to work part-time during their training. The adaptation programme is now coming to an end and although the home has passed an audit for an overseas nursing programme they have received no applications as yet. Since February 2006 they have employed seven care assistants and are in the process of employing two more. Three care staff have left. Four staff files of newly appointed staff were examined closely. All had all the required documentation and checks in place. All had completed application forms, with a full career history; several had also produced CV’s. All had a photograph and other proof of identification. All had two references and in the case of overseas references translations were available. All confirmed their mental and physical fitness and had a record of interview and all had Criminal Record Bureau and POVA first checks in place. Only one discrepancy was noted where one member of staff had two different dates of birth on documents. This is to be investigated by the home and the outcome reported back to the Commission. The home keeps a file in which the training completed by each member of staff is held together with copies of certificates to confirm this training. Recent training undertaken included Infection Control in April 2006, Moving and Handling in March 06, Health and Safety in 2006, Fire Safety in April 06. Other training included Protection of Vulnerable adults, food hygiene and continence. The End of Life care included symptom control, psychological care, communication and religious and spiritual care. Future training includes many of the above and also dementia care and first aid. Syringe driver and subcutaneous fluid training is also booked for 1/11/06 for qualified nursing staff. Kingsley House Nursing Home DS0000016486.V309354.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 & 38 Quality in this outcome area is judged to be good. This judgement has been made using available evidence including a visit to this service. The manager is well supported by her senior staff in providing clear leadership throughout the home with all staff demonstrating awareness of their roles and responsibilities. The home is run in the best interests of service users and their financial interests are safeguarded. The systems for resident consultation in the home are good with evidence that indicates that residents’ views are both sought and acted upon. The health, safety and welfare of service users are promoted and protected. Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager has worked at the home for a number of years and became manager following the retirement of the previous owner/manager. She has completed the registered managers’ award and has recently completed a clinical supervision course. She is responsible for the health and well being of the residents, staffing and the day-to-day running of the home. A satisfaction survey was given to service users/relatives prior to the last inspection and following the inspection the results were collated and a report compiled, a copy of which was sent to the inspector. Thirty-one questionnaires were sent out and eleven were returned. Seven were very satisfied with the care. Four others although generally satisfied did comment on communication sometimes being difficult with some overseas staff, one requested an extra blanket and said the call bells was not working; another said the lighting was not bright enough and staff always a appeared to be in a hurry when responding to call bells, one asked for chairs to be provided for visitors and one felt hungry on occasions between meals. Action was taken for all of the above and recorded in the report. A further survey was sent out in July 2006 and the results are yet to be collated. In addition to the above the dispensing pharmacy completes regular audits and the manager ensures that care and medication records are well maintained. Accident records are also audited and were seen at inspection. Although numbers of accidents sustained by individuals are noted and appropriate action is taken it may be also beneficial to notes times of accidents and senior staff on-duty to look for trends. At the last inspection it was a requirement that the proprietor should be carrying out unannounced monthly Regulation 26 visits and submitting monthly reports of these visits to the CSCI. Although visits and writing a report are still a requirement, there is no longer a requirement to submit this report to the Commission unless requested but a report should be available in the home to be seen. The home does not act as appointee for any residents. Family or other representatives take responsibility for the management of their financial affairs. In some instances residents/relatives hand in small amounts of personal expenditure monies for safe- keeping. A record is kept of any such money handed in and receipts are kept for any financial transactions undertaken, for example money for newspapers, hairdressing etc. No health and safety risks were identified during the tour of the home other than waste bins without lids mentioned in standard 26 above and which is Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 23 being addressed. The staff records seen and recorded above in Standards 27 – 30, confirm that all health and safety mandatory training is undertaken at induction with regular updates arranged. The pre inspection questionnaire provided indicated that regular maintenance and servicing of equipment is carried out to include fire equipment March 06; emergency lighting July 06, lift service April 06, hoists June 06 and emergency call system April 06. The most recent fire training and fire drills were undertaken in July 06and the Environmental Health Officer visited in February 06. Kingsley House Nursing Home DS0000016486.V309354.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 4 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 X X X X X X 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 X 2 X 3 X X 3 Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Timescale for action 30/11/06 2. OP9 13(2) 3. OP33 26 Review the care plan regularly with the service user or their representative where appropriate and unless it is impracticable to do so. This requirement has been repeated from the last inspection, as it has not been met in full. The timescale of 1/4/06 was not met. Ensure that medication 30/11/06 prescribed for one resident is not used for another and that shelf life of medications such as creams has not expired. The Registered Provider must 30/11/06 carry out monthly-unannounced visits to the home, compile a written report on these visits and make these reports available on request from CSCI. This requirement has been repeated from the last inspection, as it has not been met in full. The timescale of 1/4/06 was not met. Kingsley House Nursing Home DS0000016486.V309354.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 OP26 Good Practice Recommendations Provide waste bins with lids in all areas to ensure good infection control procedures. Kingsley House Nursing Home DS0000016486.V309354.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Kingsley House Nursing Home DS0000016486.V309354.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!