Inspection on 18/05/06 for Kingsmead Lodge

This inspection was carried out on 18th May 2006.

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

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

Other inspections for this house

Kingsmead Lodge 02/02/09

Kingsmead Lodge 17/01/08

Kingsmead Lodge 01/05/07

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

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 Kingsmead Lodge West Town Road Shirehampton Bristol BS11 9NJ Lead Inspector Vanessa Carter Key Unannounced Inspection 18th and 19th May 2006 08:30 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 Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 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. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kingsmead Lodge Address West Town Road Shirehampton Bristol BS11 9NJ 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) 0117 982 3299 0117 982 4515 None Mimosa Healthcare (No4) Limited Fran Haskins Care Home 81 Category(ies) of Dementia - over 65 years of age (37), Old age, registration, with number not falling within any other category (44) of places Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate up to 44 persons requiring nursing care on the first floor (Nightingale Unit) May accommodate up to 37 persons with Dementia, requiring personal care only, on the ground floor (Kingfisher Unit) One named resident under 65 years at the time of registration may remain in the home while their needs continue to be met. Registration will revert to persons over 65 years when that person ceases to be accommodated The person responsible to the registered manager, in charge of the Kingfisher Unit, must have qualifications and experience relevant to the service user group The Registered Manager must be a RN1 or RNA on the NMC register First Inspection – service previously inspected when home under different ownership. 4. 5. Date of last inspection Brief Description of the Service: Kingsmead Lodge is a purpose built home that is currently registered to provide general nursing care for older people, and personal care to people with dementia. An application has been received by CSCI to alter the category of the downstairs unit to accommodate people who need specialist dementia care nursing. The home has 81 places, of which 67 are in single rooms. These rooms all have ensuite facilities. The home also has seven shared rooms, of which two have ensuite facilities. The home is a two-storey building with lift access to the upper floor. The home has 44 beds on the first floor (Nightingale Unit) for persons requiring nursing care and 37 beds for persons with dementia on the ground floor (Kingfisher Unit). To the rear of the property there are private gardens and a patio area. The home is located a short distance from Shirehampton village, where there is a range of local shops and amenities. The bus route into Bristol passes through Shirehampton, making the home accessible from the city centre. The M5 and M4 motorways are within easy reach. The cost of placement is between £348 – 605, the price dependent upon assessed need. Prospective residents can be provided with information about the home and this will detail the services and facilities available at the home. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over two days. This inspection visit by CSCI is the first to the home whilst it has been owned by Mimosa Healthcare. Whilst the staff team remains the same, there has been a change in the senior management personnel. Evidence was gathered from a number of different sources:- Speaking with residents - Speaking with some visitors - Speaking with care and ancillary staff - Speaking with registered nurses - A tour of the premises - Examination of some of the homes records - Observations of staff practices and interaction with the residents. The home manager was not present during the inspection, but the Area Support Manager made himself available. The overall analysis is that the home is a satisfactory place in which to live and to work, but improvements in a number of areas where minor shortfalls have been noted, would improve the quality of the service for the residents and ensure that staff are always fully proficient in meeting their needs. What the service does well: What has improved since the last inspection? Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 6 There was a noticeable improvement in the cleanliness and odour throughout the home, particularly in the dementia care unit. There has been concern at two previous visits about the numbers of available bathing facilities – the bathrooms have now been made available for use by the residents, but Mimosa plan to alter one bathroom on each floor into level access shower rooms. Equipment in the kitchen that has been broken for sometime has now been replaced. 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. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 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 Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 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): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes admission procedure ensures that placement is only offered to those whose needs can be met. Prospective residents are provided with information about the home. EVIDENCE: The homes Statement of Purpose contains all the information necessary for a prospective resident and/or their representative to make an informed decision about moving to the home. Each resident is given a ‘Welcome Pack’ or service users guide and this gives details of the services and facilities they can expect to receive in the home. The home has admission criteria and will only admit people to the home whose needs can be met. The pre-admission assessment tool of one recently admitted person was examined. Information was gathered concerning their personal care needs, health care, communication and mental health needs. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 9 The home has a number of “Safe Haven beds”. People who require extra care and support for a temporary period will be admitted by their GP, rather than be admitted into an acute hospital bed, and their care will be overseen by the Rapid Response Team (a team of occupational therapists and physiotherapists jointly funded by health and local authority). Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 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, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to have their needs met and be treated properly, but improvements with the reviewing processes will ensure that information about them remains up to date. EVIDENCE: Three plans were examined from each unit. They each contained guidance for care staff into how the identified needs should be met, however some of the information was “too wordy” or “too complicated to understand”. The plans did cover a range of specific needs for each resident, but were based upon an assessment that had been carried out some time previously. This was particularly important for one such resident whose needs had recently changed significantly. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 11 It would be good practice for each resident to have a complete re-assessment of needs on a regular basis or when there has been a significant change in care needs. For the person whose health was deteriorating, they were identified as ‘at risk’ from pressure sore development, however no preventative measures had been put in place. The plans looked at had been regularly reviewed, however there was no indication of who had been involved in the reviewing process. One resident had very complex needs and the staff were taking the appropriate actions to prevent pressure sores and were monitoring fluid intake and output. Records were maintained of their actions. Wound care plans were good and provided clear indication of the exact actions the staff were expected to take, but for one person it was difficult to determine when dressing changes had occurred. The plans were supported with photography and wound mapping diagrams - helpful in monitoring progress. There was noted to be a good standard of recording in the daily notes, and this evidenced the care provided and the involvement of other healthcare professionals. The home maintains a record of GP contacts and other professionals and this evidences that the residents have access to healthcare services. The Community Matron is a regular visitor to the home and provides advice, with the aim of preventing admission of acutely ill residents into hospital. On the dementia care unit residents are visited by community based psychiatric nurses and consultant psychiatrists. There was generally a good response from residents in respects to how long it took for call bells to be answered. Observations were made of call bells being answered within a reasonable space of time. One person said “ it can take a while at certain times” whilst another stated they always got the help they needed. Observations were also made of good interaction between staff and residents, with respectful and appropriate communication. Feedback from the residents included these comments “the girls are so kind”, “I am well looked after” and “they are always so friendly”. The homes medications systems were not checked on this visit and the CSCI pharmacist will be asked to visit the home at a later date. A discussion with a manager about palliative, and end of life care plans, demonstrated the homes commitment to continue looking after a resident when they reach these stages. The home should complete advanced care plans in consultation with the resident (where possible), their relatives, GP and Hospice services. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 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 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. This judgement has been made using available evidence including a visit to this service. Residents will be given the option to participate in a stimulating and varied life, with a range of activities being organised. Residents are provided with good meals. EVIDENCE: An activities organiser is employed at the home and has been in post for many years. She is a valued part of the staff team, and the fact that she was on holiday for a week, was commented upon by a number of the residents. She has particular times to spend on each of the units however residents are able to participate in arranged activities on ‘the other unit’ if they wish. They are also able to choose not to take part and to spend their time how they wish. Posters displaying the arranged activities are displayed throughout the home and included trips out of the home, a slide show, and arts and crafts sessions. One resident had gone along to the bingo that morning and said, “it was an absolute hoot”. Residents also referred to the party that had been held at the home the previous week to celebrate “International Nurse Day”. They had enjoyed seeing all the colourful costumes, and trying the cultural foods. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 13 One visitor to the home said that they were able to visit at any reasonable time and were welcomed by the staff when they arrived. A number of ‘volunteers’ also visit the home and assist with activities and chatting with residents. The home has a four-week menu plan and these have recently been reviewed and amended. A range of comments was made about the food that included, “can’t complain”, “the food is generally very good” and, “the food is marvellous”. On the first day of the inspection the choice of midday meal was beef and mushroom pie or sausage plait – the beef was very tender, well cooked and very enjoyable. One resident was quite disruptive during the mealtime, much to the annoyance of the other residents, and staff tried distracting them to no avail. The person was eventually removed from the room and had their meal elsewhere. The resident was later seen to be calm and resting. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements in the way in which all complaints are dealt with will ensure that residents and their relatives are listened to EVIDENCE: An examination of the complaints log evidenced that the home has a system in place to log any complaints made and a procedure for recording the outcome of any investigation. This is good practice and does evidence that the home takes seriously any complaints made about their service. Looking at a sample of the complaints received and the corresponding paperwork, it is evident that complainants are provided with an outcome. However, one complaint made in February, still has not been resolved and the complainant felt necessary to refer the matter to CSCI. The home must ensure that all complaints are fully investigated and that any new issues that come to light as a result of their investigation are followed through. Because of this failure on the homes part, the standard expected is considered to “not be met”. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 15 The home has demonstrated they have a resident’s best interests at heart and will take appropriate measures to safeguard a resident from any harm. The home had informed local authority personnel, and had followed agreed protection of vulnerable adult (POVA) procedures, where there were concerns regarding one of the residents. Staff spoken to were aware of their responsibilities to report bad practice and to safeguard residents. Some said they had had POVA training, but this had been a long time ago. Discussion with the manager evidenced that this had already been highlighted by Mimosa as a training need for the staff team. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are cared for in a comfortable and safe environment. The home is fully equipped to meet their needs and is kept clean and tidy. EVIDENCE: The home is a purpose built care home, with facilities arranged over two floors. There are two lifts in between the two floors, making the home fully accessible for disabled people. The home has car parking to the front of the building and gardens to one side and to the rear. The ground floor is the dementia care unit (Kingfisher unit). It is an L-shaped unit – a number of residents use the space in the long corridors to move around in. The unit has been decorated following advice from Dementia Voice, with WC’s and bathroom doors being ‘visible’ and ‘staff only’ doors being coloured the same as the walls. The main door into the unit, the lift and all the staircases up to the first floor, are secured with keypad systems. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 17 The nursing unit is on the second floor and is a t-shaped unit, with a central nursing station. The unit can be reached via the stairway from the main reception area of via the lifts, accessed from the dementia care unit. The home is well maintained throughout. Examination of the ‘maintenance request book’ showed that any repairs are attended to promptly. There was an intermittent noise noticeable in parts of the ground floor, caused by the boiler. Some staff said they had got used to the noise. Residents did not appear to be affected by the noise. The maintenance team have called external contractors in who will arrange for repair works to be completed. Both floors have communal facilities consisting of two lounge areas and two dining rooms. Each of the rooms is well furnished with domestic style furnishings. In addition each unit has an activity/resource room, however this room on the nursing floor is used to store the hoists and stand aids. There are toilets and bathrooms located throughout the home, all of which are supplied with liquid soap, hand towels and toilet paper. The home only has two bathrooms that are fitted with mechanical bath aids (one on each floor), but some of the other baths can be used with hoisting equipment. On two previous visits to the home, the bathrooms have not been in a usable state. They have either been used as a storage area or were not “odour free” - a pleasant area in which to bathe. An immediate requirement notice was issued to the home to provide “adequate numbers of bathrooms to meet the needs of the residents” and compliance has been shown. The manager explained that there are plans to alter one bathroom on each floor into level access shower facilities. The home was clean and tidy throughout and improvements have been made with the areas of malodour previously referred to. This was particularly noticeable in the dementia care unit. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 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 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 adequate. This judgement has been made using available evidence including a visit to this service. Improvements in the induction of new staff, and the availability of purposeful training, would ensure that staff are skilled and competent to care for the residents. EVIDENCE: The home employs 16 registered nurses, 31 care staff and 20 ancillary staff. The staff team is stable and there has only been two staff leave since Mimosa took over. There is minimal agency usage, so residents can be assured they will be looked after by staff who are familiar with their needs. On previous visits to the home residents had commented that overseas nurses were unable to communicate effectively with them. One resident said that she enjoyed the “cosmopolitan” mix of staff, whilst another said she sometimes had to ask them to repeat what they had said, “but that’s because I am deaf”. The staff rotas were inspected and showed that all shifts are covered with sufficient numbers of staff. In addition to the care staff and registered nurses there are catering, housekeeping and laundry personnel. Staff spoken to during the course of the inspection, were helpful and friendly, and the care staff were knowledgeable about the residents needs. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 19 The staff team includes only a small number of care staff who are qualified to NVQ Level 2. Some of the staff are from overseas and have higher qualifications in care (nursing), therefore their qualifications are deemed to be at least equivalent to an NVQ 2. Four care have just been enrolled onto an NVQ course. Once these staff are trained, the home will be above the 50 minimum ratio of trained members of care staff. A sample of staff recruitment records was examined and evidenced that the home follows a robust recruitment procedure. This will ensure that the right people are employed to work at the home, and residents will be safeguarded. The induction training programmes for new staff members remains inadequate. The home must ensure that staff are properly inducted into their role to ensure they have the necessary skills to care for the residents. Evidence must be available for inspectors, of the process that new staff have gone through to check their competency in meeting the purpose of their job. An examination of the training files evidenced that the majority of staff have not received purposeful training for some time. During the course of the inspection, some staff attended COSHH/product training, and others to wound management training. A training review for all staff has already been completed and the training manager for Mimosa is arranging mandatory training for all staff. This is good in that any skill gaps found will be addressed. Some staff are currently working on a dementia care module. The staff training files will be inspected at the next visit to check the organisations progress in meeting the expected standard. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements in the working practices would ensure that the residents live in a home that is well managed and run in their own best interests. EVIDENCE: The registered manager is qualified, competent and experienced to run the home, however is absent for the time being. In the meantime the home has temporary management cover in place. The nursing unit has a lead nurse who has been employed at the home for many years. An acting lead nurse manages the dementia care unit. She is competent and committed to see through the change from personal care to nursing residents that is planned. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 21 Registered Nurse and care staff are encouraged to have a say in how the home is run. Meetings are held for both residents and relatives, and at the last meeting approximately 50 people attended. Residents spoken to said they are encouraged to express their views - examples include ideas for trips out, and meal choices. The home undertakes a number of audits on a quarterly basis. These include catering, health and safety, care planning documentation, laundry and housekeeping, maintenance and infection control. The auditors had noted a number of shortcomings; however there was no evidence of what action had resulted. The manager discussed the quality assurance and monitoring processes that Mimosa will be undertaking in the summer. Resident, relative and staff surveys will be sent out, and feedback will form the basis of an action plan for improvement. Formal supervision of the staff team has fallen by the wayside and records showed that only a small number of staff have had the opportunity for a 1:1 session with a senior member of staff. Staff confirmed that they have not had supervision recently. Arrangements must be put in place to ensure staff are appropriately supervised, their work practices are in line with the homes policies and that any training and development needs are identified. The standard of record keeping is good but improvements are needed with care planning documentation and the maintenance of staff training files. The home maintains a register of falls, and an individual records for each resident who falls. This is good practice and enables staff to identify trends and trigger factors, and take appropriate preventative action. All the service records for utility services and equipment are up to date. Staff records and residents files are securely kept. The home must ensure that all files including those of previous residents are properly and safely stored. The fire records were checked. Whilst all the necessary weekly, monthly and quarterly checks had been completed, there was only one recorded fire drill in the last eight months. This means that staff may have not been provided with suitable training in fire prevention, or be aware of the homes procedure to follow in the case of a fire. Mimosa has identified this as a shortfall and fire training has already been arranged. Fire drills must be arranged for day staff on a six monthly basis and for night staff, three monthly. The home must maintain evidence that all staff have participated in these drills. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 22 Staff were observed moving one resident in a wheelchair without footplates. This is a potentially dangerous procedure. All other residents were moved in wheelchairs with footplates. The home must ensure that staff follow safe working practices at all times and do not subject residents to any unnecessary risks. This was discussed with a manager and staff during the inspection. Each resident must have a thorough moving and handling assessment carried out that results in a safe system of working being formulated. This must give clear instructions to the staff on what equipment should be used for any particular transfer movement. One resident had such a document, but the practice was not evident throughout the home. This will ensure that neither residents nor staff members are hurt or made uncomfortable, due to unsafe moving procedures. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 23 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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 1 2 1 Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 14(1) Requirement The assessment of care needs must be reviewed on a regular basis or when there has been a significant change in needs. Care planning documentation must be clear, concise, kept up to date and reviewed and amended, on at least a monthly basis. (Timescale set for the previous provider has not been met) Timescale for action 18/06/06 2. OP7 15 18/06/06 3. OP16 22 4. OP30 18(1) previous provider has not been met) Complaints about the home must 18/06/06 be dealt with effectively, with complainants being provided with an outcome and actions that result. Induction training for new staff 18/08/06 must meet “Skills for Care” guidelines. (Timescale set for the All care staff must receive formal supervision. All records relating to residents, even those who no longer live in the home, must be kept secure. 18/07/06 18/06/06 5. 6. OP36 OP37 18(2) 17(1) b Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 25 7. OP38 23(4)d 8. OP38 13(4)b,c 9. OP38 13(5) Fire drills and practice must be arranged for all night and day staff on a 3 and 6 month respectfully, basis. Records must be maintained and available for inspection. Staff must follow safe working practices at all times – wheelchairs must not be used without footplates. Thorough moving and handling assessment must be carried out so that a safe system of working is devised for each resident. 18/06/06 18/05/06 18/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP11 OP33 Good Practice Recommendations Advanced care planning in consultation with the resident, family and other healthcare professionals would ensure that end of life needs are met. Quality review audits would be improved by including records of any actions taken. Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Kingsmead Lodge DS0000066342.V293604.R01.S.doc Version 5.1 Page 27 - 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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