Inspection on 24/04/08 for Kingswood House

This inspection was carried out on 24th April 2008.

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.

Other inspections for this house

Kingswood House 30/04/07

Kingswood House 09/06/06

Kingswood House 14/12/05

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Kingswood House Mays Hill Road Shortlands Bromley Kent BR2 0HY Lead Inspector Miss Rosemary Blenkinsopp Key Unannounced Inspection 24th April 2008 08:20 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 House DS0000063942.V363607.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 House DS0000063942.V363607.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingswood House Address Mays Hill Road Shortlands Bromley Kent BR2 0HY 020 8460 0273 020 8460 7836 kingswood.House@shaw.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) Shaw Healthcare Ltd Sharon Disley Care Home 39 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (26) of places Kingswood House DS0000063942.V363607.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 26) Dementia, over 65 years of age - Code DE(E) (maximum number of places: 13) The maximum number of service users who can be accommodated is: 39 30th April 2007 2. Date of last inspection Brief Description of the Service: Kingswood House is one of 6 homes, which are registered under Shaw Healthcare Ltd. The organisation has a number of residential and nursing homes throughout the UK and has its organisational headquarters in South Wales. Kingswood House is a large purpose built care home situated in a quiet residential area on the outskirts of Bromley. The home provides twenty-four hour care to a maximum of 39 residents. Residents placed in the home are admitted via the Social Services departments referral and placement system. The home has a Manager, Deputy Manager, support staff and a team of ancillary staff. The fees are £458.17 for the block contract beds purchased through the London Borough of Bromley. Privately funded residents are between £510.51 £600.00.Dementia care beds are between £624.00 - £700.00. Kingswood House DS0000063942.V363607.R01.S.doc Version 5.2 Page 5 The home provides information to residents and relatives in the form of a Service Users Guide and a Statement of Purpose is also available on request from the home. This sets out the type of accommodation and care provided. A copy of the last inspection report is also available on request from the home or the document can be viewed in the main reception area of the home. Kingswood House DS0000063942.V363607.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of the service is 2 star. This means the people who use this service experience good. The inspection was conducted over a one-day period. The Manager facilitated the inspection. Periods of observation were undertaken on the Dementia Unit and lower ground floor. Prior to the inspection the Manager had completed the AQAA and forwarded this to the CSCI. Eleven comment cards were received including six from residents, three from relatives and two from staff. During the site visit the inspector met with three relatives, several residents and one Care Manager. Staff were interviewed as part of the site visit. All of the information obtained from the sources identified above has been incorporated into this report. A selection of documents were inspected including care plans staff personnel files as well as health and safety records. Feedback was provided to the Manager at the end of the inspection. Other information which has been considered when producing this report and rating, is the information supplied and obtained throughout the year including Regulation 37 reports and complaints. What the service does well: The company has placed great emphasis on quality assurance and introduced a number of measures to audit quality. With effective quality assurances systems in place shortfalls and areas of weakness can be identified and action taken. Staff training is another area where there is significant investment to ensure staff are competent in their roles to provide care to residents. Shaw Healthcare have developed a number of systems for financial accounting to ensure that resident’s finances are safe and measures are in place for ease of auditing. The Management team has been strengthened with staff that have been transferred from another Shaw Healthcare home, which has since closed. The Kingswood House DS0000063942.V363607.R01.S.doc Version 5.2 Page 7 full compliment of management cover provides greater staff support and supervision. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kingswood House DS0000063942.V363607.R01.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 Kingswood House DS0000063942.V363607.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre-admissions procedures provide residents with the information they require prior to any decision regarding placement being made, to establish whether the service is right for them. Staff have information to ensure they can meet individual residents’ needs and on which to base an initial care plan. EVIDENCE: At the time of the inspection there were 25 residents, which included one in hospital. Of the 25 residents on site, 21 were either in transitional beds or on respite care and 4 were permanent residents. There were no residents with MRSA or Clostridium Dificile. One resident, who had a grade 4 pressure sore, was included in case tracking. Kingswood House DS0000063942.V363607.R01.S.doc Version 5.2 Page 10 The inspector selected care plans and assessment information for case tracking. There was evidence that residents had been assessed prior admission. There is a standard pre admission form, which is a tick box format with space for additional comments. In addition Social Services assessment had been obtained and in some files correspondence from members of the multi disciplinary team and hospital letters. Residents are provided with information on the services provided at Kingswood House. Shaw Healthcare have a Statement of Purpose and Service User’s Guide, which are made available within the home and prior to admission. Pre admission visits are available although not always undertaken due to the immediate nature of many of the admissions. Service agreements were in place which outlined the stated terms and conditions between the home and the resident. Kingswood House DS0000063942.V363607.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their needs will be met by staff in the home supported by members of the multi disciplinary team. Comprehensive care plans are in place, which provide sufficient information for staff to deliver the care. Medications were safely managed which provides protection to residents. EVIDENCE: A selection of care plans were randomly selected including those relating to residents with whom the inspector had met. Care plans are set out on standard Shaw Healthcare formats. Care plans reflected physical heath needs and reviews were in place although without the resident or advocates signature. Without signatures in place the inspector was unable to confirm what if any input residents have had in developing their care plan. Kingswood House DS0000063942.V363607.R01.S.doc Version 5.2 Page 12 Included within those care plans sampled was that of a diabetic resident. Within this resident’s care plan documentation was a standard nutrition care plan and a specific diabetic care plan. This care plan provided comprehensive information on diet, foot care as well as other matters relevant to the treatment of diabetes. The supporting daily events records were informative and relevant to the identified care needs. Within the care plans sampled, risk assessments were in place covering manual handling; falls, nutrition as well as other areas identified which were specific to the individual resident. In the event that high risk is identified, particularly in areas such as falls, skin integrity and nutrition, information should be available to address the issue and more frequent reviews may be required. One weight chart indicated that the resident had lost two kilos in a period of six days yet there was no information on what monitoring or additional input was being implemented. A weight chart of a second resident also indicated weight loss, which again did not reflect additional input. Elderly residents can quickly deteriorate and weight loss is a serious issue. Early interventions are required to address this promptly to prevent complications. The record of multi disciplinary visits including those by the GP was completed. The record indicated the date of the visit and a brief summary of the actions taken. Other records in the care plan include those relating to relative’s communication, a hygiene sheet and bowel chart. Information obtained form visiting Care Manager was that good outcomes had been achieved for three residents placed in the home. She stated, “ They have blossomed” In addition she added that staff had a good knowledge of residents needs and this was evident during the formal reviews. Weekly care plan audits take place. These audits identify any updating needed or amendments, which are communicated to the team. The home employs a mix of male and female staff so that gender care issues can be addressed when providing personal care. Personal care was seen to be taking place behind closed doors. Staff were observed to knock before entering bedrooms. The medication administration was observed and the staff member’s practice was safe. Medications were safely stored in a newly developed clinical room. Two new medication trolleys’ had been purchased for safe storage of medication. There was no over stocking evident. In the medication folder there was an information sheet relating to medications in use and in particular Kingswood House DS0000063942.V363607.R01.S.doc Version 5.2 Page 13 the side effects that commonly occur. This information is beneficial for staff that are administering medication to alert them to any possible contra indications residents may suffer. On the Medication Administration Records (MAR) terms such as” use as directed “ should be avoided. Full instructions need to be in place to reduce any margin for error. Those medications to be administered “PRN” need to have full instructions including the maximum dose to be given. Those records relating to received and returned medications were in place. Eye drops were dated on opening. Staff who administer medications are subject to competency procedures to ensure that they are safe to do so. Training is provided on this topic before staff are able to undertake a medication administration round. Please see requirement 1. Kingswood House DS0000063942.V363607.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15.Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of appropriate activities and engagement does not ensure that residents are stimulated physically or mentally. Choices are provided which means residents are enabled to input into their day. This promotes resident’s independence and enhances individuals’ well being. EVIDENCE: On the first floor three residents were up as the inspector arrived. The dining tables were laid in preparation for the breakfast and menus were available on the tables. On the lower ground floor three ladies were up waiting for breakfast. This area was peaceful and relaxed particularly considering the morning period. The breakfast trolley arrived with a selection of items on it including prunes, juice, cereal etc. Residents were observed to be offered a choice of breakfast items including a selection of juices, cereal etc. Kingswood House DS0000063942.V363607.R01.S.doc Version 5.2 Page 15 One resident who spent time chatting with the inspector would prefer more West Indian food as he hadn’t had an opportunity to eat this in the home. This was relayed to the Manager. Residents were well presented. Ladies had their hair done jewellery was worn and items of cloths coordinated and well groomed. Relatives were seen to come and go throughout the day. Several of the relatives with whom the inspector met visited the home frequently and had a good impression of the service. One comment was that staff are particularly good and “ there is always a lot of laughter “. Relatives stated that they were made welcome and offered a drink. The quality of the food received good feedback. The menu is presented on the back of olde time pictorial aids relating to old news headlines. These were very good. The lunchtime meal was nicely presented with good portion sizes observed. Staff assisted residents in an unhurried manner. Bowls of fruit were in the sitting areas. The home employs an activities coordinator who was in the building during the site visit. There were no formal activities taking place during the time the site visit was conducted. Residents were engaged with their relatives or staff. The lack of formal activities meant that some residents spent long periods with the TV on, some of whom were passively engaged in the activity. There was evidence during the periods of observation of signs of well being amongst residents. Residents were engaging with one another as well as their visitors. Staff were observed to offer choice and promote independence in their daily lives. Please see requirement 2. Kingswood House DS0000063942.V363607.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive complaints information is provided to residents, relatives and visitors, which provides opportunities to raise issues. Staff demonstrated good knowledge of adult protection procedures, which affords protection to residents. EVIDENCE: Shaw Healthcare have a comprehensive procedure for dealing with complaints. This procedure was on display and incorporated into several documents such as the Statement of Purpose. The complaints information sets out the time frames for initial and final responses. Head office monitor complaints to identify if there are any emerging themes. Within the information it was evident that 13 complaints had been received by the home with one resulting in an Adult Protection referral. One area of concern, which was referred to amongst the complaints received, was access to the building at weekends. This was also related to the inspector during the site visit. Long delays in gaining access to the building were said to take place due to staff being occupied with residents. This is further compounded, as there is no administration or Manager at weekends. The home records complaints on a specific complaint form. There was not an official log of the actual complaints received although these were in date order Kingswood House DS0000063942.V363607.R01.S.doc Version 5.2 Page 17 with all information relating to the investigation and outcome retained in an orderly fashion. It is recommended that a complaints log be developed and retained on site. Comment cards referred to the Manager as an avenue for referring concerns. Those staff interviewed had a good knowledge of adult protection procedures and were aware of the need to record and report such matters. They were aware of the internal avenues for reporting suspected or actual abuse including external bodies. Staff were aware of the implications should they have to whistle blow and that Shaw Healthcare had policies and procedures referring to such. Please see recommendation 1 and 2. Kingswood House DS0000063942.V363607.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are provided with an adequate standard of accommodation. Sufficient equipment in relation to mobility aids and pressure relieving mattresses are provided to meet residents needs. The spacious corridors, lift access and specialised equipment all add to benefit resident’s daily lives. EVIDENCE: The accommodation at Kingswood is laid out over three floors on three separate units. Each unit has private and communal accommodation. The main kitchen and laundry are on the ground floor, which also comprises the main offices. There is lift access to all floors. The lift was in full working order. All toilet facilities are wheel chair accessible. There is a smoking room available for the residents on the lower floor, which has an air purifier unit to enable residents to be in a clean environment. Kingswood House DS0000063942.V363607.R01.S.doc Version 5.2 Page 19 Throughout the home the wide corridors, the addition of sitting and dining areas in each unit, are beneficial for residents. The width of the corridors allows for wheelchairs and mobility aids to be used. Generally bedrooms were in the main personalised. Residents are consulted with regard to decoration of their rooms and other areas. This is discussed in residents meetings. Communal araes were homely. Areas were generally clean and tidy. On going efforts are required to maintain the home to its current acceptable level until closure. Bathrooms were of a good size and contained soap and hand-towels. One bathroom has a Malibu bath. This is particularly useful for those residents who have mobility impairment. Other items of equipment were available and in use throughout the visit. Kingswood House DS0000063942.V363607.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers with an appropriate skill mix to meet the resident’s needs. Ancillary and administration staff work to support the care staff. Robust recruitment procedures afford protection to residents living in the home. Staff are provided with training and induction to enable them to undertake the work they perform. EVIDENCE: During the morning period the staffing levels comprise of two Team Leaders and five care staff to cover the home. The Manager is supernumerary. The top floor, which is the Dementia Care Unit, is staffed by one Team Leader and two care staff. Within the home there is one Team Leader who works a mix of day and night duty by her own choice. This was said to be working very well as she could see the issues from both shifts and had facilitated more team working between day and night staff. This had enhanced relationships in the home and led to greater consistency when delivering resident’s care. Kingswood House DS0000063942.V363607.R01.S.doc Version 5.2 Page 21 Five staff are currently doing equality and diversity training through an external local college. The home has recently also had a new Deputy Manager transferred from Ann Sutherland House, which has closed. A Team leader from Ann Southerland House has also been transferred to Kingswood. The Manager advised the inspector that agency hours had significantly reduced. Seven hours of agency staff had been used in the week previous where as on some occasions 100 hours had been used in one week. A number of staff were interviewed during the site visit. All confirmed that they had received a lot of training including mandatory updates as well as those topics specific to residents such as Dementia. This information was also confirmed in comment cards, which were returned. Several of the staff interviewed had completed NVQ training. A selection of topics were chosen to establish their knowledge and they demonstrated a good knowledge on those topic asked. Staff confirmed that their opinion there was sufficient staff numbers to meet resident’s needs. Training records obtained through the administrator, confirmed the training provided. Staff personnel files were selected for inspection. Recruitment procedures are undertaken through head office. A pro forma form is retained in the personnel file to confirm items such as POVA /CRB clearance and references have been obtained prior to commencement of employment. Health questionnaires were available and completed. Once appointed employees are issued with job descriptions, terms and conditions and contracts. Appraisal and supervision records were on file. Copies of the company induction forms were in the files. Probationary periods are in operation for all employees of Shaw Healthcare. Kingswood House DS0000063942.V363607.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced individual who operates an open door policy to promote transparency. Health and safety issues are well addressed which provides residents with a safe home in which to live. The homes quality assurance systems help to continually improve the quality of care provided and to ensure the safety and well-being of those living there EVIDENCE: The Manager has been in post for 2 years. The Manager was successfully registered with the Commission in November 2006. She has a number of years Kingswood House DS0000063942.V363607.R01.S.doc Version 5.2 Page 23 experience as a carer and Deputy Manager before being appointed Manager of Kingswood House. She has completed the RMA. The Deputy Manager has also completed the RMA. The Manager operates an open door policy whereby any resident, relative or visitor may speak to her confidentially. This was confirmed through feedback received. A selection of Health and Safety certificates were inspected and found to be in good order confirming that the home and equipment are well maintained and safe for residents. Items of lifting equipment had been inspected January 2008. An environmental health inspection had been conducted January 2007. The handyman conducts monthly audits in respect of health and safety issues in the home. The home had an individual fire risk assessment which was completed December 07. Other fire records provided evidence of regular weekly alarm testing and monthly emergency lighting testing. General health and safety issues were monitored during the tour including hot water temperatures, window restrictors and radiators, which were found to be satisfactory. Items, which require safe storage, were stored appropriately. The home has a designated health and safety officer who has completed training for this. There was a list of staff first aiders in reception. Quality assurance measures in the home are addressed through in house auditing, meetings and surveys as well as Head Office standard checks. The quality department of Shaw Healthcare visit every six months and audit the home. Following these audits a report is produced and an action plan to address shortfalls implemented. Comment cards are sent out via post to relatives to seek their views on the service on a three monthly basis. The information obtained through this process is collated and any shortfalls actioned. Regulation 26 visits are conducted and a report on the findings left. Resident’s monies were checked, two staff signatures are in place to confirm transactions. Money is retained in individual wallets. Receipts were in place for all expenditure. The administrator conducts financial audits frequently. Kingswood House DS0000063942.V363607.R01.S.doc Version 5.2 Page 24 Kingswood House DS0000063942.V363607.R01.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 X X 3 X X X 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 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Kingswood House DS0000063942.V363607.R01.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 OP9 Standard Regulation 13 Requirement The Registered Manager must ensure that all information regarding medication is recorded including full instructions for those medications to be given “as required “. The Registered Manager must ensure that appropriate activities are offered to residents. Timescale for action 30/06/08 2. OP12 16 30/06/08 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 OP22 Good Practice Recommendations The complaints procedure should be freely available in other formats such as large print. The Manager should look at alternative ways to access the building over the weekend periods to prevent visitors waiting. DS0000063942.V363607.R01.S.doc Version 5.2 Page 27 Kingswood House Kingswood House DS0000063942.V363607.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 House DS0000063942.V363607.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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