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Inspection on 27/02/07 for Kingston Nursing Home

Also see our care home review for Kingston Nursing Home for more information

This inspection was carried out on 27th February 2007.

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

The home provides a clean and comfortable environment. Residents are encouraged to bring in their own personal belongings. Residents said staff are friendly and helpful. They also said that they respect their privacy and dignity as much as they can. Residents said the availability of activities was good and it satisfied their needs. Residents are provided with a good standard of facilities both in and outside the home.

What has improved since the last inspection?

The home has provided extra seating space by providing a large conservatory at the back of the house.

What the care home could do better:

The home should ensure the information provided to residents includes a Service User Guide. Improvement is needed with the provision of care plans and risk assessments to meet residents need. When a care need or risk is identified, written information must be provided to staff to assist with meeting the need or reducing the risk to the resident as soon as possible. This is the responsibility of all registered nursing staff and not just the registered manager. The home has recognised that there are difficulties with obtaining dental services for the residents and agreed that they need to further explore this matter with the Primary Care Trust. There are some areas regarding medication that need improved. These relate to providing appropriate storage, obtaining appropriate consent to store and administer medications and also ensuring that an appropriate risk assessment has been developed for self-administration of medication. Those residents with specific diverse cultural needs must be appropriately assessed and assisted to have their needs met whenever possible. Improved safeguarding adult systems are needed and a better understanding of what might constitute abuse. Two adult protection concerns were identified during the inspection. The records did not show evidence that the home had appropriately investigated these concerns by following their adult protection policy. The recruitment procedure adopted by the home must be reviewed and improved, as the current system does not thoroughly protect the residents living in the home. The home works in partnership with Investors in People and is working through a quality assurance workbook. However, evidence must be provided to show how the home is maintaining and improving the quality of care provided to the people who live in the home. This was not presented at the inspection.The information held relating to residents in the home must be securely stored in line with the Data Protection Act 1998. There needs to be a review of the health and safety practices adopted by the home. There were a number of practices identified that placed residents at possible risk.

CARE HOMES FOR OLDER PEOPLE Kingston Nursing Home Kingston House 7 Park Crescent Leeds Yorkshire LS8 1DH Lead Inspector Sean Cassidy Key Unannounced Inspection 27th February 2007 09:00 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 Kingston Nursing Home DS0000001349.V299215.R02.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. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingston Nursing Home Address Kingston House 7 Park Crescent Leeds Yorkshire LS8 1DH 0113 2666520 0113 2664171 kimkahachi@yahoo.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) B & C Holt Limited Mrs Kim Mahachi Care Home 37 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (37), of places Physical disability (1), Terminally ill over 65 years of age (5) Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place for PD is for the service user named in the variation application dated 3 April 2006 16th February 2006 Date of last inspection Brief Description of the Service: Kingston House is a thirty-seven bedded care home for older people situated in the north of the city of Leeds and provides nursing care. The home is registered to care for five people within the registered number who are suffering from terminal illness and require specialist care. The bedrooms are located over four floors; these are accessed by a passenger lift and are a mixture of single and double rooms. Assisted bathing facilities are available as is other specialised equipment. The home operates a no smoking policy. The home is off the main road but regular bus services are in operation. There is parking available at the home for visitors with cars. There are gardens to the front and side of the building and a conservatory has been added to the rear. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence in this report has included: • • • A review of the information held on the home’s file since the last inspection. Information submitted by the registered provider in the pre inspection questionnaire. Information received from service users, relatives, staff and other professionals. An Unannounced visit to the home was conducted by one inspector and lasted one day. The majority of this time was spent speaking to residents, management, staff and relatives. The visit included a tour of the premises. A number of documents were examined which included care files, training files, recruitment files and health and safety details. What the service does well: The home provides a clean and comfortable environment. Residents are encouraged to bring in their own personal belongings. Residents said staff are friendly and helpful. They also said that they respect their privacy and dignity as much as they can. Residents said the availability of activities was good and it satisfied their needs. Residents are provided with a good standard of facilities both in and outside the home. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home should ensure the information provided to residents includes a Service User Guide. Improvement is needed with the provision of care plans and risk assessments to meet residents need. When a care need or risk is identified, written information must be provided to staff to assist with meeting the need or reducing the risk to the resident as soon as possible. This is the responsibility of all registered nursing staff and not just the registered manager. The home has recognised that there are difficulties with obtaining dental services for the residents and agreed that they need to further explore this matter with the Primary Care Trust. There are some areas regarding medication that need improved. These relate to providing appropriate storage, obtaining appropriate consent to store and administer medications and also ensuring that an appropriate risk assessment has been developed for self-administration of medication. Those residents with specific diverse cultural needs must be appropriately assessed and assisted to have their needs met whenever possible. Improved safeguarding adult systems are needed and a better understanding of what might constitute abuse. Two adult protection concerns were identified during the inspection. The records did not show evidence that the home had appropriately investigated these concerns by following their adult protection policy. The recruitment procedure adopted by the home must be reviewed and improved, as the current system does not thoroughly protect the residents living in the home. The home works in partnership with Investors in People and is working through a quality assurance workbook. However, evidence must be provided to show how the home is maintaining and improving the quality of care provided to the people who live in the home. This was not presented at the inspection. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 7 The information held relating to residents in the home must be securely stored in line with the Data Protection Act 1998. There needs to be a review of the health and safety practices adopted by the home. There were a number of practices identified that placed residents at possible risk. 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. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 8 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 Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 9 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 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are appropriately assessed prior to moving into the home. Although the home has developed a Statement of Purpose the residents do not benefit from the provider providing them with a Service User Guide. EVIDENCE: The home has produced a pack that provides the reader with information about the registered service. The manager said all new residents are provided with this pack when they are admitted and all existing residents have been provided with one. Residents who provided feedback as part of the inspection said they were unfamiliar with the document. There is confusion about what is a Service User Guide and what is a Statement of Purpose. The information available is the Statement of Purpose but there is Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 10 no Service User Guide in place to assist residents when they move in. The manager was provided with advice on where to go to obtain suitable information to develop this document. The care files examined showed the home ensures residents are assessed prior to being admitted to the home. Residents and relatives confirmed that they did have the opportunity to visit the home prior to moving in. The home does admit residents in an emergency and there is an emergency policy in place. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. The home show a good awareness of the resident’s immediate care needs. Residents would benefit from improved care planning and risk assessment. EVIDENCE: The care files for five residents were inspected both prior to the site visit and also during the site visit. The care plans provided the reader with good information about how care needs should be provided. Risk assessments were completed in areas such as moving and handling, nutrition, pressure area care and falls. The documents were reviewed monthly and the home has obtained consent from the residents and their families where possible. There was evidence in the care documentation to show that a person centred care approach is adopted in the care plans. This is good practice. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 12 Some areas of concern were identified within the care documentation that need addressed. These are: • Some resident risk assessments and care plans had not been developed until the resident had been in the home for as long as three weeks. This places residents at possible risk. Three resident files had identified care needs in areas such as continence, nutrition, pressure areas and falls. No care plans were developed to assist staff with meeting these needs. This is poor practice. One resident had a care plan developed to assist staff with dressing a wound. No diagram was provided to assist staff and the records indicated that the wound had not been dressed for over twelve days. The wound was described as being “necrotic/ pussy” but the care records did not show any action had been taken to address this issue. One resident care file identified that that two hourly pressure area care should be administered to alleviate pressure. There were no records to show this care was given. • • • Residents spoken to were positive about the staff responding to their health care needs. The records inspected showed other health care professionals such as general practitioners, dieticians and chiropodists made regular visits to residents. Residents’ files also showed that consent was obtained for the administration of the flu vaccine. One resident did express concern about not having access to a dentist as she was having difficulty with. This was referred to the manager who said there are ongoing problems with accessing dentists. The manager confirmed that she would follow this up again with the Leeds Primary Care Trust. Residents spoke highly of the care staff and said they felt the staff were very helpful and courteous when they were providing their personal care. Carers were observed carrying out their roles during the inspection and they were respectful and attentive to resident needs. They were observed to knock on residents’ rooms before entering and residents said this was always general practice. The medication charts inspected were filled in correctly and the controlled drugs kept in the home were securely locked away. There were a number of practice issues that were raised with the manager that must be implemented. These are: • Consent must be obtained from the resident or their representative to store and administer their medications. DS0000001349.V299215.R02.S.doc Version 5.2 Page 13 Kingston Nursing Home • • There is no risk assessment available to assess whether a resident is able to self medicate. Medications were not stored securely. The medicine room also acts as the manager’s office and is left open and unattended. The fridge containing medicines was open and the trolley was not secured to the wall. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 14 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. The majority of residents are happy with the provisions the home has made to meet their social and cultural needs. However, improvement is needed to ensure the cultural and diversity needs of residents are provided for. EVIDENCE: An activity organiser is employed two half days a week. At other times activities are either staff led or provided by entertainers who are brought in. Residents and relatives are kept informed of any activities through the use of bulletins. Residents spoken to said that they are happy with the activities that are on offer and they choose themselves what they want to get involved with. A number of residents said that they enjoyed the outings that have been provided recently. Taxis are used to take the residents to more local places. Staff try to ensure everyone has a chance to go out and include as many residents as possible. Residents said that during the good weather staff take them to the local shops Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 15 or parks. Those using wheelchairs are also accommodated. The residents spoken to said they had enough to do during the day and enjoyed the trips out. Residents were happy with the visiting arrangements that were provided in the home. They said they were able to attend religious services if they wanted to. Local church representatives make regular visits to the home. Visitors are welcomed at the home and residents go out with their families if this has been agreed. One resident said she goes out with her relatives regularly. The mealtime in the home was observed during the visit. This was a social occasion and staff interacted well with the resident group. Those that needed assistance were provided with it in a dignified manner. Most residents said that the standard of the food was good and that they had a choice. Three residents spoken to said they were not happy with the food they received and would like to see an improvement. The manager could not provide evidence to show how residents are consulted about the food they are provided within the home. They are asked what they want to eat and they can have alternatives made if they wish. The cook has developed a four-week rota for the menu with a different variety of meals on offer. There are residents living in the home that come from a different cultural background and have different food tastes than the majority of the residents in the home. One of these residents said how it would be appreciated greatly if the home could provide meals that suit her tastes. This was highlighted with the cook and the manager. The manager did say that they have tried in the past to meet those needs. There were no records kept to show this did happen. The manager said that they will reassess how they can attempt to provide for these needs. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 16 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. The staff showed a good awareness of safeguarding adult issues and residents felt well protected. However, a better awareness of what constitutes abuse is needed. EVIDENCE: Those residents spoken to and contacted during the inspection said that they felt comfortable about making a complaint if they needed to. They knew where to go to make a complaint. The complaint policy is displayed in the home. The registered manager said that they have not had any complaints since the last inspection. There is a complaint document to record complaints appropriately. Although the manager has not had any formal complaints, the home has received information in the service user/representative questionnaires that highlighted concerns regarding the heating and the hot water systems. No evidence was provided to show that these concerns were looked into and an outcome obtained. Some staff were spoken to about safeguarding adults. There was a good awareness of what constitutes abuse and what action they should take if abuse Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 17 was identified. There are policies and procedures in place to provide guidance to all staff in this area. Two safeguarding issues were identified and referred to the manager. It was recommended that advice be sought from the local safeguarding adults office as to how they should deal with the issues. Both cases highlighted should have been referred to the safeguarding adults unit for advice to ensure the residents were being appropriately protected. The documentation needed to show that the manager had investigated these matters and provided staff with the appropriate guidance to manage the situations was not provided. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 18 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall environment of the home is clean and accessible. EVIDENCE: The layout of the home is suitable for the needs of the resident group living there. There are large accessible gardens, which residents said they do access in the good weather. They also said fetes are put on during the summer months. The home offers a welcoming, comfortable atmosphere and residents are able to access all areas of the home. Maintenance work is carried out on a need basis and also is planned for over the course of the year. The manager and staff team make efforts to ensure the accommodation is welcoming, comfortable and pleasantly decorated. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 19 Residents said that they felt the cleanliness within the home was of a good standard. There are domestic staff employed that work hard to maintain this standard. Some comments made were, “ It is always spotless.” “ The domestic staff do a good job.” There was a strong odour identified in one of the residents’ rooms, which the manager was aware of. It was also noted that some of the bedroom carpets were stained and in need of attention. Those rooms were identified with the manager and assurances were given that this would be investigated Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 20 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. This judgement has been made using available evidence including a visit to this service. Staff receive a good standard of induction and training. Recruitment procedures adopted by the home do not thoroughly protect the resident group. EVIDENCE: Residents said the staffing levels of the home were good. There is a staff rota developed over a four weekly rota. This highlights the staff on duty for all shifts over that period. The numbers identified for all shifts were consistent. Residents said staff were reasonably quick to respond to their needs. “They don’t take long to answer the call bell.” “ They will do extra little jobs for me if I ask.” A resident used the call bell when the inspector was in the room and the staff were quick to attend. Those spoken to said they felt confident in the staff group and that they were suitably trained to do their job. Staff spoken to said they did receive job descriptions and were able to give a good overview of their roles and responsibilities. The home employs several foreign nurses who are completing their nurse adaptation courses. They are employed as carers in the care home. All new Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 21 employees complete a thorough induction pack, which was evidenced during the inspection. Staff receive training in different areas relevant to the resident needs. In the Pre Inspection Questionnaire the manager highlighted the training that has been provided to staff. This includes; wound care; palliative care; dementia care and nutritional care. Over 50 of the carers have been trained to NVQ Level 2 or above. The recruitment procedure was inspected. The recruitment files of the two most recent members of staff showed evidence that the required information needed before commencing employment had not been obtained. One had commenced work before a POVA check had been obtained and did not have any references. The other carer had been employed on the basis of references that had been brought with her to interview. This is poor practice. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 22 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, 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. The resident group would benefit more from improvement in the systems and processes used by the home to improve quality of care and health and safety. EVIDENCE: The manager has worked in the care home environment for many years. She has obtained training in management to NVQ level 4 standard and has also obtained further training in this are. She tries to ensure the home provides an open door policy for all groups. She shows a good awareness of her role and responsibilities. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 23 A Quality Assurance questionnaire is sent to relatives, staff and residents on an annual basis to obtain their views. The questionnaires were examined and they contained positive and negative information. The manager has not yet developed a system to correlate the information she has obtained and present it to all interested parties. The home does work in partnership with Investors for people and the manager said the home has started to work through a quality assurance file. This is good practice. However, the manager was unable to provide evidence to show how outcomes for service users are measured and what system is used for maintaining and improving the quality of care provided. The manager said that the provider does visit the home regularly but does not carry out a mini audit when he is there. These provider assessments help to provide evidence that resident care and the premises are being assessed at regular intervals. A good number of thank you letters from grateful families and friends were seen confirming that people think the service offered at the home is very good. Regular staff supervision sessions are in place with written records kept. All supervision is provided within a group scenario. It is good practice to provide one to one supervision. Some members of staff felt this would benefit them as well. The manager confirmed that the home is not responsible for any resident monies. This should be clearly documented in the Statement of Purpose and the Service User Guide when it is written. The homes records are up to date and reviewed regularly but there was a problem with how they are storing personal information about residents and staff. The open door policy adopted by the home means that anyone has access to the information stored in the manager’s office. This is poor practice and the manager was asked to review the situation as soon as possible. An identified person regularly checks the equipment used in the home. Hot water temperatures are also regularly checked. A recent fire authority inspection made a number of recommendations, which the manager said they have nearly completed. There were some concerns identified regarding Health and Safety in the home. These were: • • The doors to sluice rooms were not secured and therefore were accessible. The door to the basement was not properly secured and was a potential risk. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 24 • • • There is an apparent culture to wedge all doors, including fire doors, open. There is no environmental risk assessment carried out on the home. The fire escapes do not have alarms on during the day and therefore staff cannot be alerted to the fact that a resident is outside unaccompanied. The home does not have anyone trained in the area of risk assessment. • All of the above pose a potential risk to all those using the service. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 25 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 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 3 2 2 Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 26 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 OP1 Regulation 5(1) Requirement The registered person must ensure all residents receive a Service User Guide that contains all the required information. The registered person must develop care plans and risk assessments to assist staff in meeting the care needs and also protecting the resident from harm. The registered person must ensure residents have access to a dentist. A self-medication risk assessment must be developed to assist residents wishing to maintain their independence in this area. Drugs must be securely locked away at all times. Consent must be obtained from residents if the home is storing and administering their medications. 5 OP15 12(4)(b) The registered person must ensure that residents with DS0000001349.V299215.R02.S.doc Timescale for action 31/05/07 2 OP7 15(1) 31/05/07 3 4 OP8 OP9 13 12,13 30/06/07 31/05/07 31/05/07 Kingston Nursing Home Version 5.2 Page 27 6 OP17 12 7 OP26 12(2) 8 OP29 19, Schedule 2 24 9 OP33 10 OP37 17 11 OP38 13(4) differing cultural needs in the area of food are provided for. The registered person must ensure appropriate action is taken to ensure all residents are properly protected. The registered person should ensure all parts of the home are clean and free from offensive odours. The registered person must adopt a thorough recruitment policy to ensure residents are properly protected. The registered person must ensure there are continuous selfmonitoring processes in place that help to maintain and improve the quality of care provided in the home. The registered person must ensure all personal information relating to residents and staff is securely locked away at all times. The registered person must ensure that the necessary steps are taken to ensure residents and others are not placed at risk of harm. (This relates to the health and safety issues.) The practice of using wedges to hold doors open must cease due to the fire safety risks this practice raises. 31/03/07 31/05/07 31/03/07 30/06/07 31/03/07 31/03/07 Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 28 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 OP36 OP16 Good Practice Recommendations The manager should introduce regular one to one supervision sessions with the staff. The manager should identify what information can be treated as a complaint and investigate it appropriately. Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Kingston Nursing Home DS0000001349.V299215.R02.S.doc Version 5.2 Page 30 - 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. 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