Inspection on 23/05/07 for Kingswood Court

This inspection was carried out on 23rd May 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kingswood Court 04/02/08

Kingswood Court 10/09/07

Kingswood Court 04/05/06

Kingswood Court 10/11/05

Kingswood Court 31/05/05

Kingswood Court 24/02/05

Kingswood Court 14/12/04

Kingswood Court 21/06/04

Kingswood Court 24/05/04

Kingswood Court 15/02/04

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 Kingswood Court Soundwell Road Kingswood South Glos BS15 1PN Lead Inspector Melanie Edwards Unannounced Inspection 22 and 23 May 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 Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingswood Court Address Soundwell Road Kingswood South Glos BS15 1PN 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 9603722 0117 9603744 Grandcross Limited(wholly owned subsidiary of Four Seasons Health Care Ltd) Mr Aubrey Sibiya Care Home 66 Category(ies) of Old age, not falling within any other category registration, with number (66) of places Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. May accommodate up to 66 persons aged 50 years and over who are receiving nursing care. Of the total 66 persons, up to 3 persons (who must be 65 years or over) may be accommodated and provided with personal care only. Manager must be a RN on parts 1 or 12 of the NMC register Staffing notice dated 22/6/1998 applies. May accommodate one person under the age of 50, who has physical disability. This condition relates to a named person and will lapse if the person leaves the home. 4th May 2006 Date of last inspection Brief Description of the Service: Kingswood Court is a purpose built home, operated by Grand cross Ltd, which is affiliated to Four Seasons Health Care. The home is registered to provide nursing care for 66 people over the age of 50. It has ample car parking space at the rear and a small garden in front separating it from the main road. There is access to local shops, amenities and bus routes. Accommodation is provided over three floors; each floor has its own lounge and dining area. There is level access throughout the home and a lift to each floor. Toilets and bathroom facilities are adequate for the number of residents and have adaptations to meet their assessed needs. All rooms are equipped with call alarm systems. Visitors may visit at any time. The fees charged for staying at the Home for care range from £359 to £471 per week. Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 16 of the 56 residents currently living at Kingswood Court were consulted to find out their views. Mr Sibiya is the registered manager; he is currently absent from the Home. In his absence a peripatetic manager (someone who steps in, and runs Care Homes if managers are absent), Mrs. Lyn Doyle is running the Home. Mrs. Doyle, three registered nurses, and the chef were interviewed about their roles and responsibilities, training needs, and how they assist and support residents. Staff were observed assisting residents with their needs. A portion of lunch was sampled in the company of a small group of residents. A selection of records relating to the day-to-day running and management of the Home were inspected. A range of resident’s care records and care plans were checked and inspected. The majority of the environment was seen, the only areas not checked were a small number of bedrooms. There were a number of pre-inspection feedback forms sent to the Commission for Social Care Inspection area office, from residents, and relatives. This information has been used to help form the judgements in the report. The written views of the Primary Care Trust Nurses who carry out assessments of residents nursing needs have been included and form some of the judgements in the report. Susan Fuller our Pharmacist Inspector carried out an inspection of medication standards. The report of her visit is available from the Commission on request. What the service does well: What has improved since the last inspection? Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 6 The resident who has a footpad alarm system in operation by their bedroom door now has an assessment in place. This is to support the reasons for the use of the alarm, and actions staff should take when it rings. The garden grass has been cut and is suitable for residents to use. 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. The summary of this inspection report can be made available in other formats on request. Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3. Quality in this outcome area is adequate. Residents’ needs are assessed. Residents and their representatives are provided with information to make an informed choice about living at the Home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: To find out how prospective residents and their representatives are helped to find out about the Home a copy of the service users guide and the statement of purpose were inspected. Each resident is given their own copy of the guide so they have access to information about life in the Home. Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 9 The guide includes information about the service provided, the qualifications of the staff employed, and the accommodation. The philosophy of the Home and how the service aims to meet residents’ needs is included. The complaints procedure is in the document for residents to know how to complain about the service. However the statement of purpose and the service users guide have not been written in a format that is `user friendly’. Also there are few pictures of the Home, or community included in the guide to help inform the reader about the service. Some residents would benefit if the service users guide were written in a format that is easy to read. Mrs. Doyle has recently updated the statement of purpose and service users guide and made sure that all current information about the Home is included. To find out how the care that residents need is being planned, six assessment records were looked at in detail. There was a nutritional needs assessment for each resident to show what the residents dietary and nutritional needs are. There was also a skin vulnerability assessment completed for residents. The assessments show that the residents’ risk of developing pressure sores has been assessed. (The skin vulnerability assessments will be referred to again in the next section of the report when care plans are written about). There are risk assessments in place to support residents to be able to maintain their own safety in the Home. There are risk assessments for residents who require bedside rails. The assessments had been signed and dated, to show who carried out the assessment and when they did it. The benefit of these risk assessments is that they should help staff to support residents in their daily lives. The staff on duty were assisting residents with their needs in a friendly way during the inspection. A number of residents expressed a range of views about the care and service they received. Examples of comments made by them about the staff and the Home included, ‘ the staff are quite good they vary ’, `the majority of staff have all been very friendly, the staff say they are very busy ’, `they look after me very well ’, ‘I wouldn’t want to be anywhere else ’, and `I like most of the carers’. There were a significant number of comments made in residents and relatives survey forms that referred to a lack of staff. There were also examples written about when residents said they had to wait what they felt was an excessively long time for help to go to the toilet. (This will be written about further in the staffing section of the report). There are no residents at the Home solely for intermediate care. Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8.Quality in this outcome area is poor. Some residents’ care plans demonstrate how needs are met. However the Home is failing to put in place care plans for all residents. Also care plans do not show how to meet residents’ cultural needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Six care plans were inspected to find out how residents are supported to meet their needs. The care plans seen set out how to meet the care needs of some of the residents. Care plans included information for staff to follow to support residents with physical, psychological and communication needs. Care plans had been reviewed and updated regularly by registered nurses. This helps demonstrate residents’ needs are reviewed. Included with care plans were assessments for each resident of their nutritional needs, their skin pressure vulnerability and the risks of the person falling. Registered nurses are reviewing assessments on a reasonably regular basis. This helps to demonstrate staff monitor residents’ assessed needs. However a number of residents whose care plans were read had been assessed as having very vulnerable skin. These residents did not have an up to date care plan saying how staff would make sure the person’s skin stayed intact. This lack of a care Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 11 plan for these residents puts them at risk of developing pressure sores if staff do not have a plan of care to guide them in their actions. One resident who needed to be moved in bed at least every four hours, had not been moved for over five hours according to the record of when staff had last assisted them. This omission could lead to the residents skin breaking down if it were repeated. In discussion with the temporary manager they showed the inspector a copy of recent staff team notes. In these notes the manager has required that all residents assessed as having vulnerable skin that may get sore, must have a care plan in place to show how to try and prevent this happening. This is evidence of effective management by the temporary manager, as they have already identified failings that need addressing as a matter of high priority. The content of all of the care plans failed to reflect residents’ unique cultural and diverse needs. This was particularly noticeable for one resident, as their care plan failed to reflect their culture, and the impact this may have on their needs. There was information written in residents’ care records that recorded any specialist needs the resident had, including if they saw a Doctor. The records showed GPs. see residents on a regular basis to attend to their health. Two GPs. were visiting the Home for appointments with residents. A physiotherapist was observed carrying out an assessment of one resident’s mobility. This helps to demonstrate that outside professionals support residents with health needs while they live at the Home. In discussion with registered nurses on duty, they were able to explain how they were helping residents with their needs and conveyed that they had an understanding of the residents they were caring for at the time. Staff were observed knocking on doors before entering the rooms, and communicating with residents in a friendly manner. Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15. Quality in this outcome area is adequate. Residents are provided with a generaly satisfactorily nutritious diet, and can take part in a range of social and theraputic activities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents can take part in different social and therapeutic activities with the support of the activities coordinator who works four days a week . In the afternoon small groups of residents went for walks in the garden with the activities organiser and care staff. This was good practice, and helps ensure residents can sit outside on a sunny day. While staff were clearly very busy, they were seen spending some time when they could talking with residents about social matters. This is clearly beneficial and its importance for residents should not be underestimated. There was information about the social activities being planned in the Home on display in the Home. A variety of low-key social activities as well as occasional trips, about once every five weeks, out into the community take place. Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 13 A hairdresser service is available during the week and this is an opportunity for residents to be able to have their hair attended to at the Home if they so wish. The residents’ menu was reviewed to see what range of meals choices residents are offered. The Home operates a four-week flexible menu. The menu was looked at in detail, and there was a range of varied and traditional meals provided. The chef on duty demonstrated, in discussion, their commitment to trying to provide a well-cooked and nutritious diet to residents. The lunchtime meal was observed being served on two floors of the Home. The meal choices consisted of either cottage pie, or home made cheese and onion flan, and fresh vegetables and potatoes. The meals were tasty and were satisfactorily cooked. However the presentation of the cottage pie could have been made more appetising for residents as the mashed potato had been served separately from the mince and gravy with which it was cooked. The pudding was a sponge with condensed milk. It was disappointing that a number of residents wanted custard that was not available, and other residents had no condensed milk. This meant the pudding was a dry consistency. The lack of custard or condensed milk also meant some residents with very vulnerable health and who benefit from extra protein, missed out on this in the custard or condensed milk. Staff were working hard serving food to residents in their rooms, and to residents sitting at dining room tables. Residents needing extra help with their meals were being helped in a discrete way by staff, to help maintain the person’s dignity. Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is adequate. Residents’ and their representative complaints will be taken seriously and acted upon. However, residents would be better protected if all staff involved in caring for residents attend up to date training on the subject of protection of vulnerable adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a copy of the complaints procedure on display in the reception area. This includes the contact information for the area office of the Commission for Social Care Inspection. A copy of the complaints procedure is included in the service user guide. The pre-inspection questionnaire completed by the Home, said that there had been fifteen complaints recorded since the last inspection. Three had been fully substantiated. The most recent complaint related to care matters in the Home and had been promptly dealt with by a senior Four Seasons manager. The Home has its own `protection of vulnerable adults from abuse’ procedure. This is the basis for actions taken in the event of an allegation of abuse. This is to help all staff follow the correct course of action to protect residents in the event of an allegation of abuse. Four Seasons have their own in house training booklet on the subject of `protection of vulnerable adults ’. The information seen in the booklet is Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 15 particularly relevant to helping staff in the work they do. However the majority of staff haven’t attended recent training on the subject of protection of vulnerable adults from abuse. This training is needed to help to ensure residents are protected from the risk of harm or abuse. Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,25,26.Quality in this outcome area is adequate. The Home looked adequately maintained,and generaly suitable for residents needs. However while the Home looks clean there is a strong and unpleasant odour in parts of it. Also paintwork in much of the Home now looks very worn and faded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Kingswood Court Care Home is a large property that was built as a nursing Home. It is situated in the suburb of Kingswood, near Bristol. The Home is built over three floors, that can be reached by stairs or lift. The building is about a twenty-minute car ride away from Bristol City Centre. There are local shops, a library, a church, pub and Cossham Hospital nearby. The environment was generally clean and tidy throughout, and domestic staff were working hard cleaning the Home. However on two floors of the Home Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 17 there was a strong and unpleasant odour present. Action needs to be taken tomake these parts of the Home odour free. There is a range of specialist equipment and adaptations in place throughout the Home, to assist people who may have reduced mobility. The majority of bedrooms and all the communal areas were viewed. The majority of bedrooms are for single use, however there are two double rooms. Rooms were generally adequately decorated and maintained. However it is very noticeable that the paintwork in many parts of the Home is becoming ` tired looking and worn. The residents’ environment would be improved if redecoration were to done in the Home as a matter of priority. All bedrooms have en suite facilities, and there are bathrooms and toilets located close to rooms. There are suitable adaptations in toilets and bathroom to assist people who have reduced mobility there is also lift access to the first and second floor. There are three dining rooms and three television lounges. Communal living areas were light and spacious. Residents were observed sitting in communal areas looking comfortable. Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,30. Quality in this outcome area is poor. There are insufficient staff employed to consistently meet residents needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff duty record for nursing and care staff for the previous two-week period was checked. This was done to find out if residents are cared for by a sufficient number of staff on duty to ensure needs are met. For the current number of 56 residents there is a minimum of three registered nurses and nine care staff on duty every morning shift. There are three registered nurses and seven care staff on an afternoon shift, and two registered nurses and five staff on duty at night. There was some sickness recorded, where possible the Home try and cover any shortages of staff with their own staff, there has been some use of agency staff as well. There are also domestic staff, catering staff, and laundry staff who work in the Home every day, however the numbers of these staff were not reviewed. The local Primary Care Trust team of nurses who assess residents for continuing health care needs have very recently written to the Home. The nurses expressed concern that with the current high dependency levels in the Home, and difficulty in retaining staff, residents needs are not being met. Examples of personal care needs not being met, as well as a lack of availability of call bells were mentioned as examples of how care needs are not being met. A number of residents survey forms were sent back to us before the inspection. There were ten references made by residents and relatives to a lack Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 19 of staff and how this had affected their needs being met. Based on all of the evidence from the inspection a review of the staff numbers and an increase in numbers of staff must happen to make sure residents needs are met. The training records of three members of staff were looked at to find out if staff attend training opportunities. These consisted of three care staff and one registered nurse. The staff concerned had attended some recent training and update sessions on topics and matters relevant to the needs of residents in the Home. The National Vocational Qualification in care award trainer was in the Home meeting with care staff who are in the process of undertaking this award. This will be beneficial for residents when the majority of care staff are National Vocational Qualification in care trained. There were training notices and information on display at the nursing station about forthcoming study days. This benefits residents if staff are well motivated and undertake regular training and updating. However staff also reported that they had very recently had to cancel a health and safety study day that had been planned for members of the team. The staff reported that this was due to a lack of staff on duty. Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,36,38.Quality in this outcome area is adequate. Having a temporary manager running the Home while Mr Sibya is absent is beneficial for residents and staff. The health and safety systems and procedures in place help protect the health and safety of residents, staff and visitors. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mr Sibiya is the registered manager who is currently absent from the Home. While he is absent Mrs. Lyn Doyle is running the Home. Staff spoke positively of Mrs. Doyle and her management style. She also has considerable experience in running a number of Care Homes on a temporary basis for Four Seasons. A sample of staff supervision records was looked at on this inspection. These showed evidence that registered nurses and care staff have been supervised in their work and practice. Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 21 The monthly monitoring visits of the Home that must be carried out by a representative of Fours Seasons Care Limited are being undertaken as is required by law. There are records of these visits. The environment looked safe and adequately maintained (see comments written in the environment section of the report). A full time maintenance worker is employed. However he is currently off sick. While he is absent maintenance staff from other Four Seasons Homes carry out maintenance work. This helps demonstrate the health and safety of residents’ staff and visitors is being maintained. Mrs. Doyle is in the process of booking staff on a range of health and safety training course .This is beneficial so that staff keep up to date in their knowledge of health and safety practices.This should make sure residents health and safety is protected. The fire logbook record was checked and showed the required fire tests and checks were being carried out and were kept up to date. This helps to maintain the safety of everyone inside the building. Staff have attended fire safety training in the last twelve months. This training is required so that staff understanding what they need to do in the event of a fire in the Home. The kitchen staff have recently achieved the local environmental health food safety award for which they are to be commended. This award helps to demonstrate kitchen staff are following good health and safety practices and procedures in food safety and preparation. However when inspecting the kitchen it was observed that there is no pedal bin. The bin in current use requires that staff lift its lid with their hand. It is more hygienic to use a pedal bin as it minimises the risk of cross infection. Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 22 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 X X 3 3 2 STAFFING Standard No Score 27 1 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 3 3 3 Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 18. (1) Requirement The Home must be able to demonstrate all residents’ needs are met: There needs to be a review of the staff numbers and an increase in them to meet all residents’ needs. Residents assessed as having vulnerable skin must have an up to date care plan setting out how to prevent this happening. Parts of the Home have a strong and unpleasant odour present: Action must be taken to make these parts of the Home odour free. Timescale for action 23/07/07 2. OP7 15. 01/08/07 3. OP26 16.2(k) 30/05/07 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 OP38 Good Practice Recommendations A pedal bin should be provided in the kitchen so that staff lift the lid with their foot and not their hand: This is more hygienic, and minimises the risk of cross infection. DS0000020249.V336022.R01.S.doc Version 5.2 Page 24 Kingswood Court 2. 3. OP18 OP7 All staff should attend training in understanding the principal of the protection of vulnerable adults. Care plans should reflect how residents cultural and diversity needs are met. Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Kingswood Court DS0000020249.V336022.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!