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Inspection on 19/04/06 for Knowle House Nursing Home

Also see our care home review for Knowle House Nursing Home for more information

This inspection was carried out on 19th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home was clean and comfortable and had a homely and friendly atmosphere. While visiting the lounge and conservatory both inspectors were pleased to see the residents participating in different activities that were taking place during the day. The atmosphere was one of fun and many of the residents were chatting and laughing. Some areas of the home had been re-decorated and new carpet laid. New furniture and bedspreads were on order including new chairs for the lounge and furniture for the resident`s bedrooms. Some of the resident`s bedrooms contained their own small items of furniture and personal possessions making their rooms personal for their needs. The staff numbers were good to ensure the residents were provided with a good standard of care and observations of staff and residents showed the staff were courteous and caring. It was noticed that staff took time to stop and talk with the residents. The residents spoken with had nothing but praise for the staff saying they worked very hard and were kind and caring.

What has improved since the last inspection?

The home has appointed Victor Dias as the Acting Manager for the home who is in the process of making an application to the Commission of Social Care Inspection to become the Registered Manager. Due to the lack of leadership within the home following the recent resignation of two managers it was good to hear from the staff that they felt supported now that a manager was in post. Victor had already started to make some changes by setting up a procedure to ensure the staff made regular checks on the resident`s welfare during the night and day. All staff were now wearing name badges that also identified their status in the team. Since the last inspection in November 2005 there had been two complaints via social services with regard to concerns on the standard of care provided for two of the residents in the home. The providers responded promptly to the concerns raised and a recent letter was sent to the home and the Commission from social services expressing satisfaction and pleasure at the positive improvements made. Following the return of the maintenance man from long-term sick the in- house checks were now being carried out at regular intervals. The recent appointment of a new activity organiser appears to be working well and as previously stated it was a pleasure to see the residents participating and enjoying a variety of activities. Plans are also in place to complete an activities programme following discussions with the residents and taking into account their interests and hobbies.

What the care home could do better:

The resident`s care plans and assessments are in some cases inconsistent and poorly documented. All residents should have a contract of the terms and conditions of living in the home and a copy of the Service Users Guide. It is understood that the contracts are in the process of being reviewed. All complaints should be recorded giving details of the investigations, actions and outcomes.

CARE HOMES FOR OLDER PEOPLE Knowle House Nursing Home Lingfield Road East Grinstead West Sussex RH19 2EJ Lead Inspector Mrs J Hough Key Unannounced Inspection 19th April 2006 10:00 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 Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 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. Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Knowle House Nursing Home Address Lingfield Road East Grinstead West Sussex RH19 2EJ 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) 01342 317740 Yourcare Ltd Post Vacant Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th November 2005 Brief Description of the Service: Knowle House is registered to provide personal care and nursing for 35 residents aged over 65 years in the category of older persons (OP). Knowle House is a large detached three-storey house situated in a residential road near the town centre of East Grinstead. Accommodation is provided in 19 single bedrooms, 12 of which offer en-suite facilities, and 8 shared bedrooms, 2 of which offer en-suite facilities. A passenger lift provides access to most of the bedrooms. There is a lounge and conservatory, which is also used as a dining room situated on the ground floor, and there is a small lounge on the second floor. Knowle House is owned by Yourcare Ltd and Dr Sivasubramanian is the Responsible Individual for the company. The Acting Manager for the home is Victor Dias who is in the process of completing his application to the Commission of Social Care Inspection to become the Registered Manager. Fee levels for the home From: £518.00 to £610.00. Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out the unannounced inspection that took 7 hours. Victor Dias the Acting Manager was present at the inspection and provided the information required. All the key standards were assessed on this occasion. A tour of the premises took place and all areas were seen including the resident’s accommodation. Resident’s care plans and needs assessments; the accident and complaint logs, medication and maintenance records were examined. Residents, staff and visitors were spoken with to find out their views of the home and the services it provides. Six requirements and one recommendation were made as a result of this inspection. Two requirements are outstanding from the last inspection in November 2005. What the service does well: The home was clean and comfortable and had a homely and friendly atmosphere. While visiting the lounge and conservatory both inspectors were pleased to see the residents participating in different activities that were taking place during the day. The atmosphere was one of fun and many of the residents were chatting and laughing. Some areas of the home had been re-decorated and new carpet laid. New furniture and bedspreads were on order including new chairs for the lounge and furniture for the resident’s bedrooms. Some of the resident’s bedrooms contained their own small items of furniture and personal possessions making their rooms personal for their needs. The staff numbers were good to ensure the residents were provided with a good standard of care and observations of staff and residents showed the staff were courteous and caring. It was noticed that staff took time to stop and talk with the residents. The residents spoken with had nothing but praise for the staff saying they worked very hard and were kind and caring. Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The resident’s care plans and assessments are in some cases inconsistent and poorly documented. All residents should have a contract of the terms and conditions of living in the home and a copy of the Service Users Guide. It is understood that the contracts are in the process of being reviewed. All complaints should be recorded giving details of the investigations, actions and outcomes. Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 7 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. Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 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 Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all the residents have a copy of the updated Service User Guide, or a copy of the terms and conditions of the home. Admissions to the home did not in all cases have a full assessment completed. The home does not provide intermediate care. EVIDENCE: The home had updated the Statement of Purpose and Service User Guide in January 2006. However it was noted that not all the current residents had a copy of the revised Service User Guide. However one resident spoken with said that on admission to the home the staff were very good to me and explained everything to me. Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 10 Those residents who are admitted to the home via Social Services do not have a copy of the terms and conditions of residency for the home besides the contract from Social Services. The home is in the process of reviewing the contract of terms and conditions and all residents should receive a copy once finalised. All residents had a pre-admission assessment carried out prior to moving into the home but in some cases these were incomplete. Following the appointment of the new Acting Manager Victor Dias he will undertake all future pre-admission assessments. Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to this service. The assessments and care plans examined were inconsistent in identifying the needs of the residents. The medication procedures for the home ensure all medicines are recorded, stored, administered and disposed of safely. The resident’s privacy and dignity is upheld. EVIDENCE: Care plans and assessments were examined as part of the case tracking of four residents and the assessments were generally detailed in identifying the individual needs of the residents although one assessment had not been fully completed on the assessment format but had been written on a separate sheet that was not signed and dated. The care plans did not provide the actions Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 12 needed by the staff to meet all the resident’s needs as identified on their assessments. The care plans were generally brief in setting the actions needed by the staff to meet the resident’s needs. However, with talking to the residents it was clear that their needs are met and the care notes are not a true representation of the care provided. Some of the care plans had been reviewed at regular intervals but not recorded as being done on a monthly basis. Arrangements are made for the residents to attend any specialist clinics or health services, and all the residents spoken with had chosen their own GP. The home has the appropriate equipment for the residents accommodated with assisted baths, hoists and pressure relieving mattresses. The medication administration records were examined and were generally well completed, and no gaps were noted in recording administration of medicines. Handwritten entries on the MAR charts were not signed and dated and did not give the number of medicines stored. New front sheets had been introduced to the MAR charts with the resident’s photograph and personal details including any known allergies. The Controlled Drugs administered in the home were checked and found to be correct. However there were two bottles of liquid medication that were in the Controlled Drugs cupboard that should have been disposed as the residents were no longer accommodated in the home. The home has a contract with a clinical waste company whom make the necessary arrangements for the disposal and collection of any disposed medication. From previous inspections and speaking with the residents it showed that the residents privacy and dignity is respected at all times by the staff. Personal care is provided in the privacy of their bedrooms or bathrooms and screens are used in shared accommodation. Residents commented that the staff were courteous and kind when attending to their needs. Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a varied programme of activities taking into account the wishes of the residents. Visitors are made welcome in the home. The residents are able to make choices on what they would like to do. The residents are offered a nutritious and well-balanced diet. EVIDENCE: Since the last inspection in November 2005 the two activity organisers have left and a new organiser had recently started who was originally a care assistant in the home and who works four hours a day during the week. Plans are in place to provide a weekly programme of activities following discussions Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 14 with the residents on what they would like to do. During the day many activities were taking place with skittles, scrabble and drawing in the lounge and conservatory and for those residents who had chosen not to take part, it was good to see them enjoying watching the other residents participating in activities. The general atmosphere in the communal areas was one of fun. For those residents who had chosen not to participate in the activities and wished to stay in their own rooms, it was good to read on their care plans that the activities organiser had taken time to talk with them on a one-to-one basis. On speaking with the residents who were participating in the activities it was clear that they enjoyed these sociable events. The home has an open visiting policy but does ask visitors to avoid mealtimes where possible. Visitors are welcome to sit in the communal areas or in the resident’s own bedrooms if preferred. Observations on the day of the inspection showed that the staff made visitors very welcome. Comments made by two visitors were that, ” The home is friendly and welcoming” and ” I do not think you could get any better”. The kitchen was visited during the course of the morning and was found to be clean well ordered and equipped appropriately. The cook, who had undergone appropriate training in Safety in Food Handling, informed that he had been given information regarding each residents’ personal likes and dislikes and any health and dietary needs that they might have. He also said that he was able to speak to them personally on a regular basis. The written evidence displayed on the notice boards in the kitchen confirmed this. The menu for the week was available and identified that a well-balanced, varied and wholesome diet was provided to the residents. There did not appear to be any alternative meal choices available, this point was highlighted in one of the returned quality assurance surveys that had been given out at the beginning of April. The cook informed that an alternative would always be provided if a resident did not like the main dish of the day. It was recommended that an alternative to the main dish be offered at the main meal of the day. All required records regarding fridge temperatures etc were available and recorded on a daily basis in a logbook but the food taken each day was not recorded. A meal provided to the residents at lunchtime was sampled and found to be well cooked, tasty and appetising. A recent visit from the Environmental Health Officer revealed some small issues that had now been addressed. The dining room was appropriately equipped and the residents were seated around round tables on chairs that had been designed to maximise their Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 15 independence and safety. This was seen to promote a good social interaction and when talking with the residents they confirmed that they enjoyed their mealtimes and the food. On observation the staff members were seen to be discreet with any help that was required and appropriately deferential to any wishes that the residents expressed Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recording of complaints needs to be more detailed. All staff attends training on Adult Abuse. EVIDENCE: On checking the complaints log it was noted that there had been five complaints recorded since the last inspection in November 2005. It was not clear on the forms used for recording all complaints what the investigations, actions and outcomes were following each complaint. The home has a complaints procedure in place that states complaints will be responded to within a maximum of 28 days. Training records showed that all staff attended training on adult abuse and those spoken to understood their responsibilities in immediately reporting any incidents or allegations of abuse. Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 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): 19,26. Judgement : Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. The premises were well maintained and homely. EVIDENCE: A tour of the premises was made and generally the premises were well maintained with a homely atmosphere. Some re-decoration and replacement of carpets in some areas had taken place. New furniture and bed covers are on order for resident’s bedrooms and new armchairs for the lounge. It was noted that some washbasins in resident’s rooms had warning signs of very hot water and did not have valves fitted to prevent the risk of scalding. Risk assessments should be in place for those basins and is was recommended there be a maintenance plan to have valves fitted to all basins in the near future. The rear garden to the home was mainly laid to grass and was well maintained and attractive. Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 18 The local fire service had carried out a fire safety check in November 2005 and improvements required following this assessment had been completed or were in the process of being done. The resident’s bedroom that contained a fire exit was seen, and due to the exit having to be accessible at all times this was causing problems for the resident accommodated in that room. Due to the armchair having to be positioned away from the exit the resident was only able to watch television from the bed. The layout of the room made it impossible to re-arrange the position of the bed or chair. The possibility of moving to another bedroom had been discussed with the resident, but declined. The home was clean and fresh in all areas. The laundry was clean and tidy with hand washing facilities and all washing was handled following the correct infection control procedures. There were adequate sluicing facilities situated on each floor. Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 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): 27,28,29,30. Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. It was considered that the registered person had made significant improvement in the areas of recruitment and training since the last inspection. The home is run with good staffing numbers and skill mix of staff. EVIDENCE: There were twenty-one residents residing at the home at the time of inspection. On the day of inspection there were two trained level one nurses and four carers on duty excluding the Acting Manager and a similar number of nursing/care staff in the afternoon. In addition there was an activities coordinator working for four hours in the morning. There were two domestic workers (one house, one kitchen) and one cook until 2pm. One kitchen domestic in the afternoon managed the provision of afternoon tea and supper. There were sufficient waking night staff members on duty to reflect the numbers and needs of the residents and the layout of the home. The residents spoken to confirmed that they considered that there was always enough staff on duty and they generally answered the bell quickly and only on rare occasions had to wait. An examination of staff files and conversation with the care staff team revealed that there was a good skill mix and level of knowledge of the resident group Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 20 within that team. There was a recorded rota that showed which staff members were on duty at any time of the day or night. The Acting Manager informed that the home used a number of bank staff and never resorted to agency staff. There were two care vacancies and the bank staff team was covering these. Three other members of staff had tendered their resignation. The files of the staff members that had been recruited since the last key inspection were examined and seen to contain all information required by the National Minimum Standards. New staff members are only confirmed in post following the completion of a satisfactory CRB and Protection of Vulnerable Adults check. It was seen that the registered person operates a thorough and robust recruitment procedure. Training files were examined at random for three members of staff and it was seen that a number of in-house training sessions on relevant service related subjects had been undertaken including moving and handling fire safety, adult abuse. It was seen that new members were given a comprehensive induction and each person held a care assistant’s progress record. One member of staff had NVQ level III and one other was undertaking NVQ level II. The Acting Manager had commenced the Registered Manager’s Award. It was also noted that many of the care staff had social care or nursing qualifications/degrees from their country of origin. Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 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): 31,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run taking into account the best interests of the residents. The home maintains accurate records of any money held for residents. Staff supervision has not been carried out within the required timescales. The health and safety of the residents and staff are protected as far as practicable. Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 22 EVIDENCE: There has been a general lack of leadership within the home following the resignation of two managers within the past year. Victor Dias the Acting Manager was appointed in March 2006 he is a registered nurse and has had experience working as a deputy manager in care home. Some changes have taken place already with each resident having there name on their bedroom doors, staff wearing name badges and procedures put in place to ensure the residents who are unable to call for assistance are regularly checked by staff. The registered person carries out a yearly quality assurance survey and one had been initiated at the beginning of April 2006. Feedback had been sought from residents, their families’ friends and other stakeholders. A number of the questionnaires had been returned and the feedback reflected that in the main the stakeholders and residents were satisfied with the service provided Constructive criticism on some forms echoed some of the observations made by the inspectors on the inspection day i.e. the lack of choice at the main mealtime. The administrator informed that the results would be collated and generate a report and action plan to address those issues that were seen as negatives. It was not possible to assess the overall impact and importance that the results of the survey might have on the running of the home due to the fact that it was only in the early stages of development. The results of the quality assurance exercise will be used to inform the inspection record for future reference. The policy of the home is not to handle large sums of money for the residents and records showed that small amounts of spending money are held and accurate records and receipts are kept for all transactions. The residents who have chosen and are able to manage their own money are supported to continue to do so. Formal staff supervision had taken place for all staff but had fallen behind due to the lack of a manager in the home. Following the appointment of the new Acting Manager, Victor Dias, plans were in place to ensure all staff had supervision at least six times a year. The maintenance records were examined and all systems and equipment had been serviced and maintained at the appropriate intervals by the maintenance man or outside contractors. As previously mentioned the improvements needed following the fire safety assessment carried out by the local fire service in November 2005 had been completed or where in the process of being done. All accidents, injuries and incidents were recorded and reported to the appropriate authorities. Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 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 2 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 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. Standard OP7 Regulation 15(1) Requirement The registered person must ensure that a care plan is generated from a comprehensive assessment and sets out in details the action needed by staff to ensure all aspects of the health, personal and social care needs are met. (Previous timescale set for 31/12/05) 2. OP16 22 (8) The registered person must ensure that all complaints are recorded giving the actions, investigations and outcomes. (Previous timescale set for 31/12/05) 3 OP3 14(ad) The registered person must ensure that new residents are admitted only on the basis of a full assessment being undertaken. Risk assessments should be completed for those washbasins where warning signs are in place DS0000031332.V290440.R01.S.doc Timescale for action 31/05/06 31/05/06 31/05/06 4 OP38 13 (4c) 31/05/06 Knowle House Nursing Home Version 5.1 Page 25 5 6 OP36 OP2 36 5 (bc) for very hot water. Formal staff supervision should 31/05/06 take place for all staff at least six times a year. The registered person must 31/05/06 ensure that all residents have a copy of the terms and conditions of living in the home 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 BS2 Good Practice Recommendations All residents should have a copy of the Service User Guide Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Knowle House Nursing Home DS0000031332.V290440.R01.S.doc Version 5.1 Page 27 - 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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