Inspection on 12/01/06 for Kite Hill Nursing Home

This inspection was carried out on 12th January 2006.

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

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

Other inspections for this house

Kite Hill Nursing Home 23/05/06

Kite Hill Nursing Home 06/06/05

Kite Hill Nursing Home 19/01/05

Kite Hill Nursing Home 07/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Kite Hill Nursing Home Kite Hill Wootton Bridge Isle Of Wight PO33 4LE Lead Inspector Mark Sims Unannounced Inspection 12th January 2006 13:45 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 Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 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. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kite Hill Nursing Home Address Kite Hill Wootton Bridge Isle Of Wight PO33 4LE 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) 01983 882874 01983 883059 Colville Care Limited Margaret Groves Care Home 31 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (31), of places Physical disability over 65 years of age (10), Terminally ill over 65 years of age (5) Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is also registered for two places for people under 65 years of age, within the categories of TI, PD and DE 6th June 2005 Date of last inspection Brief Description of the Service: Kite Hill Nursing Home is situated on the main Newport to Ryde road and can be located fractionally beyond Wootton Bridge as you head from Wootton to Ryde. Access to the home can be achieved via public transport, the local bus company running a scheduled service that passes the home or private transportation, with car parking available to both the front and side aspects of the home. The premises is a large period property that has been extended and adapted to provide residential accommodation across two floors, all floors accessible via a combination of passenger lift and platform lift, ensuring all rooms are accessible to service users and visitors. The accommodation provided at Kite Hill is exclusively single occupancy, a large proportion of the rooms containing open plan en-suite facilities that are screened off from the rooms via curtains/screening. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was undertaken unannounced and formed the second statutory inspection of the year for Kite Hill Nursing Home. The inspection focused on those core standards not addressed at the 6th June 2005 inspection and various sources of evidence were considered in the formulation of judgements: records, observations and discussions with service users, their representatives, staff and management. What the service does well: What has improved since the last inspection? The home was last inspected on the 6th June 2005, at which time a number of requirements and recommendations were made, where the home was found not to be meeting the required standards. Following that visit the management of the home submitted to the Commission an action plan setting out how they intended to remedy the shortfalls noted during the inspection. At this visit those areas where the home had failed to attain or maintain the required standards were revisited and found to have been addressed in accordance with the action plan put forward. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 6 1. All medications were being appropriately and securely stored during the visit. 2. All remaining beds within the home that were not height adjustable have been replaced, the beds purchased being of a particularly good quality and designed in a wood effect. 3. All chemicals, which had previously been left in the kitchenette, had been removed and appropriately returned to the maintenance store. 4. Service users are no longer being expected to wear clothing that was not specifically brought for them, or has been passed on with consent from both parties. 5. All radiators have been recovered to ensure the risk of harm, even if deemed to be a low risk, has been covered. In addition to the work completed in addressing the requirements and recommendations of the last inspection, the proprietary company has decided to upgrade the fire safety features within all wings of the home. Work has also commenced on the home’s extension, which once complete will provide additional communal space for the service users, as well as additional en-suite bedrooms. Whilst chatting with staff it was mentioned that following a meeting with the company directors it had been recognised that the dependency levels of the patients was increasing and therefore additional staffing hours were required in the afternoon, traditionally a quieter time of day, which saw a reduction in the number of available staff around the home. What they could do better: A number of issues came to light during the inspection, which the manager should seek to address. 1. Whilst it is acknowledged that many staff these days have completed units within their National Vocational Qualifications (NVQs) which focus specifically on adult protection issues, this educational tool alone is not sufficient to ensure staff continue to be competent and/or knowledgeable on matters relating to adult protection. Many of the staff employed at Kite Hill Nursing Home attained their NVQ certificates some time back and the knowledge they gained whilst valuable cannot be considered either current or up to date. The home also employs a large number of qualified staff who are not required to complete an NVQ, given their professional status, however the training tool available to them in house was created by the United Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 7 Kingdom Central Council for Nursing and Midwifery (UKCC), a body that was replaced by the Nursing and Midwifery Council (NMC) in 2000. Taking these factors into consideration, as well as the fact that staff when asked confirmed they had not received or attended any adult protection updates, leads to the conclusion that the home is not providing suitable or adequate training around this important subject. 2. The management has created a communication sheet for staff which is used to record basic care information, i.e. bathing etc. for each service user. However, in developing this form it would appear the home has failed to consider the implication or impact the Data Protection Act and Freedom of Information Act might have on how this information is documented, as each sheet contains information relating to a number of service users. The management and company directors would be advised to seek guidance or to review how the records have been drafted, ensuring there is no breaching of the regulations associated to the two Act’s mentioned above. 3. Whilst reading through the communication sheets it became apparent that the staff are either not using the correct codes for the care provided or that they are not ensuring people’s hygiene needs are being appropriately met, it appearing as though some service users may not have received a bath or bed bath, depending on their dependency level, for upwards of 9 days, a wash alone not considered adequate attention to a person’s hygiene needs. The manager should seek to discuss this with staff and to ensure, as identified, that the correct code is entered onto the record sheet, or that people are appropriately supported with regards to meeting their personal hygiene needs. 4. Only one new staff member had been recruited since the last inspection visit, however on reviewing this person’s file it was evident that: • They had inadequate reference checks, the first reference provided being a photocopied reference brought to the home by the applicant, the second reference not available in writing and no evidence to support the claim that a verbal check had been taken up. That no photographic identification was available or documentation which established the person’s identity. • The management must take steps to ensure that these issues are addressed immediately and that in future all appropriate checks are taken up prior to the person commencing employment. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 8 On a positive note the company had obtained both a Protection Of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) check; and had conducted an interview (records of interview seen), obtained a completed application form (and associated information) and commenced a period of induction. 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. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 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 Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None All core standards were reviewed at the last inspection and there have been no concerns with regards to the home’s ability to continuously meet the required criterion in respect of the remaining standards, therefore none of the above standards were reviewed at this visit. EVIDENCE: None. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 8, 9 & 10. The health care needs of the service users are not being effectively promoted by the actions of staff. The procedures now in place to safeguard service users’ medications are effective. The service users were happy with the way the staff promote their right to privacy and respect. EVIDENCE: Unfortunately many of the people seen during the inspection were unable to effect communication with the inspector, this being a combination of their frail condition or a desire to retire to bed, as the inspector was touring the premises. However, where people were available to speak to the inspector they were very complimentary of the service being provided, the patient occupying the NHS contract beds pleased with the level of treatment they were receiving, both form the home’s staff and visiting health care professionals from the NHS. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 12 The service users staying permanently at the home also commented on the care they receive and the assistance that the staff provide in ‘keeping them going’, this phrase used by an individual who was discussing how the staff help him exercise or mobilise, an important facet of his personal care needs. In addition to the observations of the service users, the home also maintains a large amount of documented evidence to support the fact that the service users’ health care needs are appropriately attended to, including: • • • • • • Entries in the general running records. Medical records. Contact details for general practitioners, (Dr Manning providing medical cover for the NHS patients and Dr Martin retained by the company for the purpose of providing medical cover for the permanent patients) Contact details for allied health care services, (Speech and Language Therapist, Physiotherapist, Occupational Therapist, Intermediate care facilitators). A diary system that tracks when a person’s dressing requires changing or reviewing. A daily communications system, etc. The daily communications system currently in operation is a good idea and is a management tool the inspector has seen used in other locations, however, there remains a fundamental flaw with this kind of generic communication strategy, in as much as it records a lot of information about a lot of people in one place. It is this specific issue which should be of concern to the proprietary company, as the practice of recording personal information about a number of people on one record would appear to conflict with the requirements of the Data Protection Act 1995 and Freedom of Information Act 2004. It would be advisable for the manager or a company director to review how this document is used and/or to seek clarification and guidance on the precise requirements that relate to documenting personal information of this nature. Another issue which came to light whilst reading through the daily communication sheets was the fact that some patients appear to have gone up to 9 days without a bath or bed-bath, although everyone had received a wash, according to the records. It is possible that staff are failing to record accurately the precise nature of the care being delivered and if this is the case the manager should seek to clarify the importance for staff of maintaining accurate records. However, the alternative is that people are not being provided with appropriate levels of personal health care and support in maintaining adequate personal Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 13 hygiene standards, a situation I am sure the management will wish to address immediately. At the last inspection a couple of issues relating to the way staff handle or manage service users’ medications were highlighted, including a fridge full of medicines being left unlocked and medication delivered to the home deposited on the desk in the nurses’ office, accessible to anyone entering the home, as the office was open. On this visit these issues were specifically targeted for review and were found to be properly managed, the medication fridge locked and secure and the arrangements for medicines brought into the home amended to ensure they cannot be left unattended or unsecured. A tour of the premises was undertaken during the visit, enabling the inspector to speak with several service users and their visitors within their bedrooms. During some of these contacts the inspector was able to observe the staff at work and was pleased to note the polite and professional manner with which the staff interacted with the service user and their families/visitors. It was evident from these observations that the staff are familiar with the service users and their relatives and how they like to be addressed or greeted, with the service users either addressed by their given name or a name of their own choosing and their visitors either formally addressed using their surname or more informally by their first name. In conversation with some of the patients it was ascertained that they feel the staff are committed and caring and described them as nice, kind and helpful people. This view was supported by the comments of visitors, who felt the staff were always cheerful, polite and welcoming; and that their approach to care was very good, showing patience and understanding. One person spoken with during the tour stated that he is always offered refreshments when he visits and that staff are conscious of not interrupting the visit unless needed. A service user, who mentioned that his family are mainly located on the mainland and ring him every Sunday, commented on how the staff bring the phone to his room for him to receive his calls in private, the home having a portable payphone available for service users that can be taken to any room within the home. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 13 & 14. The service users are able to maintain contact with family, friends and community as they wish. The service users are provided with adequate means of exercising control over their day-to-day lives. EVIDENCE: As previously highlighted within the body of this report, the people residing at Kite Hill are assisted to maintain contact with family or friends using a variety of means. Visits to the home are conceivably the most common way people opt to maintain contact with each other, with a number of visitors spoken to directly during the inspection or observed attending the home during the tour of the premises. It is also documented within the report that people have access to a telephone and that this enables them to maintain contact with relatives or friends unable to visit the home directly, the one person recalling how the staff bring the phone to his bedroom for him to use whilst making or taking a call. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 15 In an attempt to promote visiting the company has established open visiting times, which are designed to be more flexible for people and thus make visiting easier, although the staff at the behest of the service users can limit visits. Details of the company’s visiting times, etc. are contained within the ‘Statement of Purpose’ documentation, which was accessible within the main lobby of the home. At the last inspection it was discovered that the staff were passing on clothing that had previously belonged to other service users but was no longer required, to supplement other people’s wardrobes. This was an archaic practice that the home was asked to cease with immediate effect, it being far more appropriate to support people in purchasing their own clothing than share items left by former patients. At this visit it was ascertained that this practice had indeed been stopped and that people were now encouraged or supported in buying their own clothes, a fact confirmed during the tour of the premises and discussions with service users, who stated the clothing in the wardrobes was their own. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 18. Staff training around adult protection issues and management is inadequate. EVIDENCE: Whilst it is acknowledged that many staff these days have completed units within their National Vocational Qualifications (NVQ’s), which focus specifically on adult protection issues, it is not wise to consider this educational tool to be sufficient, on its own, to ensure continued competence or knowledge on all areas of adult protection. Many of the staff employed at Kite Hill have held an NVQ for sometime and the knowledge they gained whilst valuable should not be considered as up to date or current. The home also employs a large number of qualified staff who are not required to complete an NVQ, given their professional status, however the training tool available to them in house was created by the United Kingdom Central Council for Nursing and Midwifery (UKCC), a body that was replaced by the Nursing and Midwifery Council (NMC) in 2000. Taking these factors into consideration, as well as the fact that staff when asked confirmed they had not received or attended any adult protection updates, leads to the conclusion that the home is not providing suitable or adequate training around this important subject. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22. The company is providing or securing appropriate equipment, given the needs of the service users. EVIDENCE: During the last inspection the home was required to submit plans to the Commission for the phased replacement of its current bedding stock and provision of height adjustable beds throughout the home, which they duly submitted. At this inspection it was noted during the tour of the premises that the proprietary company had exceeded its own timescales and that all beds within the home were now height adjustable. It was also evident that the new beds purchased were of a good quality make and that they had been designed in a wood effect finish, so reducing the clinical appearance of the apparatus. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 18 In conversation with service users occupying rooms with the new bedroom equipment it was ascertained that the beds were comfortable and relaxing and that the provision of integral bedrails was reassuring. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 28 & 29. Over 50 of the home’s staff are trained to National Vocational Qualification (NVQ) level 2 or equivalent. The home’s recruitment and selection process was not being adhered to and could therefore be considered to be placing service users at undue risk. EVIDENCE: In conversation with the manager it was established that 12 staff presently possess as a minimum an NVQ level 2 or equivalent and that 3 further staff are currently enrolled on NVQ courses, which should be completed early next year. As the home presently employs 17 care staff, 12 of whom possess an NVQ at the required level this gives the home a ratio of 70 , 20 above the 50 ratio recommended. Once the remaining 3 staff have completed their courses this could potentially take the home’s ration of staff possessing an NVQ level 2 or equivalent to 88 . In discussion with a staff member currently undertaking her NVQ level 2 it was established that the inflexibility of the new NVQ system is causing people problems and that as a result people undertaking the courses (not necessarily at the home) are finding it hard to meet the timescales set by the awarding body. The staff member did confirm that she is receiving both encouragement and support from work colleagues with her course. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 20 Normally the company is very efficient and organised with regards to the process for recruiting new staff, however, on reviewing the file of the only person recruited since the last inspection, it was noted that the home had not adhered to its own stringent process and that the carer had been employed without satisfactory information being obtained first. There were inadequate reference checks completed: the first reference being a photocopy supplied by the applicant and the second reference not available in writing, although it was claimed that a verbal check had been taken up, although no evidence to support this statement could be found. The person’s file also contained no photographic identification and there was no documentation available which established the person’s identity. On a positive note the company had obtained both a Protection Of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) check; and had conducted an interview (records of interview seen), obtained a completed application form (and associated information) and commenced a period of induction. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 35 & 38. The home is well run by a manager who is appropriately skilled and qualified. The home’s approach to supporting service users manage their finances enables people to be self sufficient and/or able to purchase items as they wish. Chemicals covered by COSHH (control of substances hazardous to health) regulations are now being appropriately stored. EVIDENCE: The manager is both a skilled and competent leader who possesses a managerial qualification, ‘The Registered Manager’s Award’, and relevant professional nursing qualification ‘Registered Nurse’. In conversation with the service users and their families it was established that the manager, as with all of her staff, is considered approachable, supportive and caring. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 22 In conversation with the staff a similar picture of the manager is created with people acknowledging that the manager is supportive and accommodating. The company historically prefer not to become involved in the direct management of service users’ finances, offering instead to support people through the provision of a tick system, the home purchasing all items required by a service user and billing or invoicing them at the end of the month. In conversation with service users this particular topic was not widely discussed, although it was established with a number of people that they have everything they want and that anything they need is provided, either by family or the home. At the last inspection (6th June 2005), it was noticed that chemicals, paints, paint strippers, etc. belonging to the maintenance person had been left unsecured within the first floor kitchenette. At this visit an inspection of this area and the cupboards revealed that all such items had been safely removed and were now being appropriately stored within the maintenance store, which is external to the home. Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X 3 X X X X STAFFING Standard No Score 27 X 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 24 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 2 Standard OP18 OP29 Regulation Requirement Timescale for action 17/03/06 17/02/06 Regulation The management must secure 12 updated adult protection training for all staff. Regulation The home must ensure that all 19 appropriate information and checks are completed prior to commencing a staff member’s employment. 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 OP8 Good Practice Recommendations The home should review the use of the communication sheet, as it is note currently designed to ensure compatibility with Data Protection and Freedom of Information legislation. The manager should ensure that service users’ personal hygiene needs are adequately met and/or accurately recorded. 2 OP8 Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kite Hill Nursing Home DS0000012562.V250233.R01.S.doc Version 5.0 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. 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