Inspection on 05/05/09 for Kingsway Care Home

This inspection was carried out on 5th May 2009.

CQC found this care home to be providing an Good service.

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

Other inspections for this house

Kingsway Care Home 03/11/08

Kingsway Care Home 15/05/08

Kingsway Care Home 22/05/07

Kingsway Care Home 23/05/06

Kingsway Care Home 18/10/05

Kingsway Care Home 13/04/05

Kingsway Care Home 02/11/04

Kingsway Care Home 01/06/04

Kingsway Care Home 25/02/04

Similar services:

Park House

Huntercombe Centre

Wellburn House

First Step

St Helens Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 20/07/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Kingsway Care Home Kingsway Langley Park Durham DH7 9TB Lead Inspector Nic Shaw Key Unannounced Inspection 5th May 2009 9:30am DS0000000724.V375393.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsway Care Home Address Kingsway Langley Park Durham DH7 9TB 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) 0191 3736167 0191 3735945 manger.kingsway@aermid.com www.aermid.com Aermid Health Care (UK) Limited Andrea Blenkinsop Care Home 47 Category(ies) of Past or present alcohol dependence (4), registration, with number Dementia (10), Dementia - over 65 years of age of places (47) Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2009 Brief Description of the Service: Kingsway Care Home is based in Langley Park, County Durham. The home is owned by Aermid Healthcare PLC and was first registered in 1992. It provides 24 hour nursing care for up to 47 residents who are 65 and over and who have dementia. They can also take up to 10 residents under 65 who have dementia. Accommodation is provided over two floors and all bedrooms offer single accommodation. There is a spacious garden and a car parking facility is provided at the front of the home. The home is situated close to local shops, pubs, and places of worship. The current fee level ranges from £425.39 to £571.69. Additional charges are made for hairdressing, chiropody and toiletries. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken.” Before the visit: We looked at: • Information we have received since the last full visit on 4th November 2009 • The outcome of the random inspection we carried out on 9th February 2009 • How the service has dealt with any complaints & concerns since the last visit • Any changes to how the home is run • The provider’s view of how well they care for people • Information in completed surveys about the home. Three residents and four staff had filled these in. The Visit: An unannounced visit was made on 5th May 2009. During the visit we: • Talked with people who use the service, staff &the manager • Looked at how staff support the people who live here • Looked at information about the people who use the service and how well their needs are met • Looked at other records which must be kept • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for • Looked around parts of the building to make sure it was clean, safe and comfortable • Checked what improvements had been made since the last visit A pharmacist inspector visited the home on 28th April 2009 to look at how the home manages medicines. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 6 We told the manager what we found at the end of the visit. What the service does well: There is a good admissions process. This helps to make sure people are provided with the right type of care at Kingsway. Relatives and friends can visit anytime they want to and people are able to make choices about how to spend their time. Residents are treated with dignity and respect and the meals are good. All of the staff have completed either the NVQ level 2 or 3 qualification in care. There has been a low turnover in staff which is good fro continuity of care. The manager knows what other training staff need and has a good training programme in place. The manager is a qualified nurse and has many years experience of care in a number of different settings. There is an obvious warm relationship between the manager and residents. The manager knows what needs to be done to improve the home and it is clear that she is working hard to improve outcomes for the residents. Residents said: “its alright” “the foods OK” “the manager is alright” “staff are good” “if I had a complaint I would tell them and get them to put it right”. “the home is very nice, not bad at all”. A relative said in a thank you card to the home: “big thanks to everyone at Kingsway for the exceptional care that XXXX has had”. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Although care plans are much better, we recommend the development of these continue. This should include involving residents and or their relatives in them. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 8 The ground floor clinic room temperature should be kept below 250C to ensure medication is stored safely. There should be more information about “as and when” medication so staff know when to give this. There needs to be information in the resident’s care plan about their personal preferences in relation to their medication. And when staff write changes to medication on the medication record, another member of staff needs to check this to make sure residents get the right dose of medication at the right time. There needs to be more information in the risk assessments. This is important so that it is clear why some people have limitations placed upon them. The complaints procedure should be displayed around the home. It should also be available in different formats, such as large print, so people know how to make a complaint. The planned work to the environment should continue until complete. And the improvements recommended by the environmental health officer carried out. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 9 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 Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The admissions process ensures that people are adequately assessed prior to care being offered. This means that residents are offered the right type of care at the home. This home does not provide intermediate care. EVIDENCE: There have been no new admissions since we last inspected. The manager told us that she would always complete an individual assessment for any prospective resident within 24 hours of a referral being made. She also Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 11 confirmed that they obtain an assessment from the placing social worker or health care professional before a new person is admitted. Residents said that they had the chance to have a look around the home before they moved in. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9&10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The information in the care plans about the resident’s health and social care needs is improving. However, further work is needed to make sure everyone receives care and support in a way that they prefer. Staff care practices preserve the dignity and privacy of the residents. Medication administration record and medicines storage & handling procedures have improved. EVIDENCE: Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 13 The care plans are developed from a number of assessment tools. These include all areas of a person’s health and personal care needs, for example, continence, mobility, communication, nutrition and risk of developing a pressure sore. The care plans we looked at contained up-to date information about the residents’ health and personal care needs. They are beginning to be written in a person centred way. For example, in one person’s care plan there was good information about what might cause them to become agitated. They have dementia and this information is important as it helps staff to understand what might “trigger” people to behave in an aggressive way. When we spoke to staff about this person they told us that noise may also contribute towards their agitation. The care plan needs to be up-dated to include this information together with any preventative action needed of staff. The care plans are regularly evaluated. And there was good written evidence of the involvement of other health and social care professionals, such as social workers and community psychiatric nurses. However, although the staff and manager confirmed that the residents received regular eye, dental and chiropody checks, there was no information in their care plans about this. Residents said that if they were unwell the staff would arrange for their GP to visit them. No-one in this home has a pressure sore. And everyone’s weight and blood pressure is checked monthly. The daily records provide good information about the care that has been given and whether or not the care plans are working. This is important as this information is used to help with the evaluation of the care plans. Some of the phrases in the care plans had not been written using plan English. For example; “always use unconditional positive regard” and may not be easy to understand. Staff said that, as well as the nurses, they write in the care plans. However, residents said they had not been involved in their care plans. All of the staff have been provided with training in privacy and dignity. Staff knew about the resident’s personal histories and encouraged conversation by talking to them about this. Staff did not stand over people when talking to them and when supporting people, for example to walk and with their meal, they made sure that they did so at a pace that suited the individual. In these ways the staff made sure that people were treated with dignity and respect. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 14 All nurses have received medicines safety update training and have access to current best practice guidance documents. The record of staff authorised to administer medicines is up to date. This makes it possible to identify who might be involved if a problem or error was to occur. The Medication administration records (MAR) contain clear records of medicines received and given. However, handwritten entries on the MAR charts had not been checked by a witness at the time they were written. The date of entry, the signature of the person making the entry and a witness signature should be added whenever possible. This makes sure that the details of changes or new medicines have been copied accurately. There was not enough information about when to give medicines which had been prescribed “as required”. And resident’s preferences about how and when they would like to receive their medicine had not been recorded in their care plans. The ground floor clinic room temperature is not being kept below 250C to ensure medication is stored safely. The manager confirmed that a fan was being fitted to address this. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Younger adults with dementia generally enjoy a variety of activities, and the range of activities available to older people with dementia has improved. Therefore residents have opportunities to lead a fulfilling lifestyle. Residents are able to maintain family and other contacts to a good degree should they wish. This ensures they do not become socially isolated. Residents are able to exercise control and choice over their lives, as far as is possible, which enables them to remain independent. Residents enjoy a varied menu and the mealtime experience is good, which promotes their health and well-being. EVIDENCE: Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 16 There is a full time activities co-ordinator. And since we last inspected they have completed life history work with each resident, finding out about their likes, dislikes, interests and daily routines. From this information activities care plans have been developed. We spoke to the activities co-ordinator who, in addition to providing a range of activities for people, also understands the importance of 1:1 time with the residents, chatting to them about their past lives and interests. There is a record kept in each person’s file about the activities they have taken part in. There is an activities programme and this is displayed in the corridor. There is also a monthly newsletter for relatives and residents informing about recent events in the home. A hairdresser was visiting on the day of our inspection. Two out of the three residents who completed surveys said that there were always activities arranged for them to take part in. There is a well maintained, enclosed, spacious garden. The activities coordinator said that he regularly supports individual residents to use the garden. However, residents are not able to use this area independently as the doors are kept locked. We spoke to staff about this who said that they kept the doors locked as they were concerned about the safety of one particular resident. This situation should be reviewed and a risk assessment in place to promote the safety of this person whilst at the same promoting the independence of other residents. Otherwise residents are encouraged to be independent. For example, after lunch a resident was supported to return their cup to the sink area in the dining room. Another resident said that they went out independently to the local shop. Residents said “you can do what you want”. There have been significant improvements to the environment to help people find their way around and therefore make choices about where to spend their day. For example, memory boxes with items familiar to the residents in them placed on bedroom doors. Some of the residents we spoke to have a key to their bedroom. However, some people do not and their bedroom doors are kept locked by staff. Although there are individual risk assessments in the residents care plans about this practise, they need to be developed further. For example, the risk assessments we looked identified the risk as being “possible loss of key due to cognitive impairment and potential for other residents to obtain the key and gain access” but there was no evidence available to confirm that his had Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 17 actually happened and therefore a risk. They also said “staff to unlock door when XXXX requests” but no further information about how each resident will communicate this. There are no restrictions on visiting times. One resident said that they regularly visited their family and stayed with them on a weekend. We sat with residents during lunch. This was a quiet, pleasant occasion where residents were able to eat their meals at their own pace. Where support was needed this was offered discretely and sensitively by staff. There is a four week menu and a choice of main meal available, as well as a cooked breakfast. The resident’s food likes and dislikes is recorded in their care plans. Residents said about the meals “the foods alright”. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an adequate complaints procedure so that people know that their views will be listened to. And safeguarding policies, procedures and staff training protect the residents. EVIDENCE: There is a complaints procedure in place and a comments and complaints book in the entrance area of the home. This is available in the Service User Guide, but not displayed around the home. The manager said that she had not received any complaints since the last inspection. Two out of the three residents said in surveys that they did not know how to make a formal complaint. Residents we spoke to said they would speak to Andrea (the manager) if they were unhappy. Staff who responded to surveys said that they knew what to do if someone came to them with concerns about the home. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 19 Staff said that they had completed training in safeguarding adults. The manager has a copy of the local authority safeguarding procedure and the company has its own safeguarding policy and procedure. There is now a system in place to ensure that the manager is notified of all potential safeguarding incidents. We spoke to staff about what they would do should they witness an incident and they were clear that they needed to report this to the manager. The manager now makes sure that any potential safeguarding incidents are reported to the local authority and CQC. Residents said they felt safe in this home. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,25&26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There have been significant improvements to the environment both in terms of refurbishment and adaptations so that the specialist needs of the residents can be met. EVIDENCE: Sine we last visited improvements to the environment include the following; Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 21 Installation of two new shower rooms, a new bathroom with hoist, a new bathroom with a specialist bath and one new bedroom with en-suite facilities. All of the bedrooms have been fully re-decorated and refurbished with new hand basins and soft furnishings. There are signs throughout the home in a variety of formats, for example pictures and large words, to help people with dementia find their way around. Handrails and light switches are bright contrasting colours to help people with dementia see them. Two new large screen televisions have been purchased for the lounges. New carpets have been laid throughout the home and there is new dining room furniture. There were no unpleasant odours when we visited and residents said that the home was always clean. One resident commented in a survey when asked what they thought the home does well said “keep it clean”. One member of staff said in a survey “environment has improved dramatically and is now more dementia orientated”. Another resident said about the home “its very nice, not bad at all”. All of the staff are currently completing training in infection control. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels are sufficient and staff work as a team. This ensures staff provide person centred care. Staff training is improving and includes specialist training in order to meet the diverse needs of the residents. This ensures staff can effectively meet the care needs of people with dementia. Staff recruitment procedures protect residents EVIDENCE: Currently there are only 21 people living in this home, all accommodated on the ground floor until the refurbishment on the first floor is completed. On duty during our visit were three care staff, a nurse in charge, the manager, three work placement students, an activities co-ordinator, administrator as well as catering and domestic staff. These numbers are sufficient to meet the needs of the residents. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 23 There has been a low turnover in staff, which is good for continuity of care. As well as the NVQ level 2 and level 3 training in care, staff have completed training in oral hygiene, palliative care, deprivation of liberty and training in the needs of people with dementia. Staff have not had specialist training on the needs of younger adults with dementia. However, three staff are completing a BTEQ qualification in dementia care which includes information about the needs of this specialist client group. The manager has developed a training programme and training arranged over the next year includes moving and handling, food hygiene and equality and diversity. Catering staff have completed training on the nutritional needs of older people. Staff said in surveys that there were “always” enough staff on duty to meet the needs of the residents. And residents said in surveys there were “always” or “usually” staff available when they needed them. Residents said about staff “the staff are good”. Staff files showed that a job application is completed and two written references and Enhanced Criminal Records Bureau check (CRB) obtained prior to a new person working in the home. The manager keeps a record of the interview she has carried out to show that this process has been thorough with appropriate questions being asked. The work placement students confirmed that a CRB check had been sought for them before they could spend time in the home. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36&38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management systems ensure the health, safety and welfare of the residents. The home operates a good quality assurance system, so that residents and/or their representatives know their rights and views will be listened to. EVIDENCE: The manager is a qualified Registered Mental Nurse and has managed this home for over 4 years. She has a range of experience in a number of different settings both in hospital and in the community. The manager is clearly Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 25 knowledgeable about the resident’s health and personal care needs. And there was clearly a good rapport between her and the residents. The Annual Quality Assurance Assessment (AQQA), this is what we ask for before we do an inspection, was returned to us when we asked for it. However, it was brief, and needs to contain more detailed information. There is a quality assurance system. This involves the manager and area manager carrying out a bi-monthly audit of care standards. This includes looking at care practices, staff training and any environmental issues. The last one was completed in April 2009. Similarly, the home’s line manager completes a monthly report about the conduct of the home, which is a legal requirement. The manager has introduced resident/relative meetings and minutes of these are maintained. These show how the manager involves the residents in decisions about the home, such as ideas for activities over Easter, as well as keeping people informed about events, such as the refurbishment programme. Staff confirmed that they get regular 1:1 meetings with their supervisor, at least every six weeks. Records of these are maintained. The manager has introduced a good system for monitoring the occurrence of accidents. This is important so that she can introduce any preventative action when this is needed. Staff have had training in health and safety issues such as moving and handling and fire safety. The manager has developed a training needs analysis so that she knows when this training needs to be up-dated. An environmental officer has visited recently and has advised that the kitchen floor be replaced. This needs to be addressed. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 26 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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No 16 17 18 Kingsway Care Home 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 DS0000000724.V375393.R01.S.doc Version 5.2 Score 3 3 3 X Score 3 X 3 X 3 X 3 Page 27 Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 28 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 OP38 Regulation 23 Requirement The recommendations made by the environmental health officer must be addressed. This is to ensure residents benefit from a safe environment. Timescale for action 31/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Care plans should continue to develop to ensure all are person centred. All should provide staff with step by step easy to understand information about what hey need to do to meet the resident’s personal and health care needs. Residents should be involved in their care plans as far as is possible. 2 OP9 Handwritten entries on MAR charts should be complete, accurate and witnessed at the time the entry is made. Enough detailed information should be recorded so that all DS0000000724.V375393.R01.S.doc Version 5.2 Page 29 Kingsway Care Home staff give new or changed medication correctly. The prescriber or community pharmacist should be asked to provide additional guiding information when medication has a dose of ‘as directed’ or ‘when required’ so that an individual medication care plan can be created. This helps to makes sure that the medication is given correctly as intended. Personal preferences as to how, where and when people receive their medicines should be recorded as part of their care plan. This is likely to result in fewer doses being omitted or refused. 3 OP14 OP16 3 4 OP19 Risk assessments completed in relation to locking residents bedroom doors should be developed further. They should include evidence of why this action necessary and how people with dementia will communicate to staff they want to use their bedroom. Risk assessments should also be completed for any situation where a limitation has been placed on a resident. For example, limiting access to the garden. The complaints procedure should be displayed throughout the home. It should also be made available in different formats, such as large print, so that everyone can read and understand the information The refurbishment programme should continue as planned until complete. Kingsway Care Home DS0000000724.V375393.R01.S.doc Version 5.2 Page 30 Care Quality Commission North Eastern Region Citygate, Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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