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Inspection on 26/09/07 for Roy Kinnear House

Also see our care home review for Roy Kinnear House for more information

This inspection was carried out on 26th September 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

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

A comment from one relative/advocate was: "...it is an excellent, loving place...". Feedback from healthcare professionals was also positive, where they are confident that the residents receive a good level of service at the home.

What has improved since the last inspection?

At the previous inspection there had been eight areas where the home had to improve. The home has taken action on all of these areas, which represents positive responses to the findings of the previous inspection, and good developments to the service. In particular, the home has taken steps to assess and minimise risks to residents and ensure that staff are more supported in their work.

What the care home could do better:

Areas where the home could be doing better are highlighted in the report and were discussed with the manager during the inspection. These include improvements to health and safety at the service, training for staff, increasing activities for the residents and ensuring a more person-centred approach is adopted at the service.

CARE HOME ADULTS 18-65 Roy Kinnear House 289 Waldegrave Road Twickenham Middlesex TW1 4SU Lead Inspector Louise Phillips Unannounced Inspection 26th September 2007 09:40a Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 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 Roy Kinnear House DS0000038036.V351080.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 Adults 18-65. 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. Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roy Kinnear House Address 289 Waldegrave Road Twickenham Middlesex TW1 4SU 020 8892 4049 020 8891 6734 roykinnear@btconnect.com 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) The Roy Kinnear Charitable Foundation Vacant Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. On the morning shift/afternoon shift/evening shift there must be: 1 Qualified Nurse 1 Senior Support Worker 4 Support Workers 2 Domestics (20 Hours each) On the nighttime shift there must be: 1 qualified nurse (awake) 1 senior support worker 2 support workers There must be no reduction in the establishments posts which currently stands at 19. 13th December 2006 2. 3. Date of last inspection Brief Description of the Service: Roy Kinnear House provides accommodation and personal care for up to eight residents who have severe learning and physical disabilities. The home provides nursing and residential care, where a qualified nurse is on duty at all times. The home is situated in a residential road in Twickenham and is purpose built. Three of the five bedrooms have patio doors leading onto an attractive and well-maintained garden. The lounge also opens onto the garden. The home is situated close to local shops and amenities. Placement fees are calculated according to need and are agreed by the home and the placing authority. The current fees range from £800 - £2,000 per week. Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. For this inspection a visit to the service was carried out by one inspector, where time was spent talking to the manager and a number of staff. A period of time was also spent seeking feedback via questionnaires sent to relatives/advocates, staff and healthcare professionals involved with the service. Questionnaires were received back from four relatives/advocates, eight staff and two healthcare professionals, and these are referred to in the report. One relative was spoken to by telephone. Care records were inspected along with other relevant paperwork. Information has also been gained from the inspection record for the service. Since the last inspection the service has increased its registration to enable it to provide accommodation and care for up to eight residents. At the time of the inspection there were six residents living at the service, with another resident due to move in soon. What the service does well: 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 Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 6 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. The resident’s needs are constantly assessed and there is current information available about the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection one new resident has moved to the home. Their care file contains information about the referral and assessment prior to their moving to the home, with details about their physical health, personal care needs, important relationships, etc. Information has also been obtained from all relevant health and social care professionals, detailing any particularly significant areas such as communication and sensory awareness. New residents moving to the service are offered day visits and overnight stays to help them decide if they want to live at Roy Kinnear House. Records are maintained of this process in the residents file. Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. The staff have a good awareness of the physical and personal care needs of each resident. Improvements are needed to ensure that all the needs of residents are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One relative stated that: “…generally the needs of my (relative) are very well met…”. Each resident receives care on a one-to-one basis and observations during the inspection are that staff have a good awareness of the physical and personal care needs of the residents. All residents were individually dressed in smart, age-appropriate clothing, and staff said that residents are supported to choose what they would like to wear each day. Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 10 The care files for a number of residents were looked at. These contain detailed information about the history, needs and interests of each resident. The manager described that a more person-centred approach to care planning is being introduced at the home, and the initial stages of this was seen. This was in the care files under the heading ‘what makes me happy?’ eg. reading stories to me, listening to music; and that ‘I let you know I am happy’ by facial expression and smiling. In addition there were details about ‘what makes me sad?’, with individual information stating things such as not being included in conversation, being rushed, not being told what’s happening. There were also behaviours and expressions of each individual that staff could identify as where the resident is unhappy. However, this information had not yet been forwarded into the care plans, which are very much based around the physical and nursing needs of the resident, with very little plans around meeting social interests. An example of this is that the care plans detail physical interventions on a morning, afternoon and evening basis, which is necessary, but does not include any leisure or recreational activities. This leads the care plans to be very task-orientated and not encompassing of the holistic needs of the residents. The task orientated care planning then affects recording in the daily log, where it is a list of all interventions by the nurse/ support worker in relation to the care plans. The daily logs provide very little information about what the resident had done, more so about what has been done to the resident. The previous inspection required that improvements are made to the risk assessments at the service. The manager described and demonstrated that two styles of risk assessment are now in use at the service. One format is of a general risk assessment for all areas of the home, whilst the other is individualised for any safety concerns regarding each resident. These include areas of risk around moving and handling, bathing, mobilising, travelling in the minibus and the use of cot-sides on each bed. Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. The staff provide some activities within the service. Feedback indicates that residents need to be more involved in more daily and age-appropriate activities within the community. Improvements need to be made to the food preparation facilities at the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Where asked where the service could improve, one relative stated that: “…my only general criticism would be around age appropriate activities such as ‘clubbing’ or going out for meals, trips to the theatre…so they are not just recipients of therapeutic music or visitors to the grounds…” The residents at the service cannot communicate verbally and staff said that sometimes it can be difficult to understand what their needs are. Staff said Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 12 that the relatives of each resident have provided information about what the resident likes to do and their interests. The care files detail each resident’s social interests, such as watching football and hydrotherapy. One resident likes people to sing to them, and staff were seen singing short songs to them throughout the day. On one occasion in the morning a staff member was seen reading a book to a small group of residents in the lounge. There is a sensory room in the garden at the home for the residents to use, and one resident was seen using this, with the support of staff. Two care files were looked at and there were records to indicate that some activities that take place outside of the home, such as hydrotherapy and visits to parks. One staff member stated that “…at around 6pm, the residents are ‘corralled’ in front of the TV, while food is prepared and reports are written…”. The manager said that she was aware that there need to be more ageappropriate activities for the residents, such as those highlighted by the relative (above), and the resident being more involved in such things as shopping for their toiletries, going to concerts, or football matches, etc. The manager said to address this the role of ‘senior support worker’ has been created, to take the lead on enhancing each resident’s life. On the day of inspection the manager demonstrated that the recruitment for this post was taking place. Most residents have contact with their relatives on a regular basis with them visiting the service. Feedback from relatives was generally positive, where they said that they are kept up-to-date with their relatives progress. However one relative did comment that they only get feedback when they ask, that they are not regularly updated by the service. One relative expressed concern with talking to staff due to language communication problems. Two staff also highlighted that it is important that all staff speak English in front of the other staff and residents. Some of the residents at Roy Kinnear House use Percutaneous Endoscopic Gastrostomy (PEG) feeds. The other residents have varying dietary needs and evidence was seen in the care files to indicate the involvement of a dietician in menu planning. The kitchen was stocked with a variety of foods, that which were labelled appropriately where jars had been opened. The freezer contained a lot of frozen, pre-packed meals, such as cottage pie and quiche. It was observed that there was no oven or hob for the preparation and cooking of meals, only a microwave, which does not promote food choices and residents to be involved Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 13 in the activity of cooking. It is recommended that the service install a cooker to enhance this activity and also the food preparation choices for residents. Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made as the feedback received from health and social care professionals and relative’s is that the resident’s physical and personal care needs are well met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The health and social care professionals associated with the service commented that the home maintains good partnership links with them, with one adding that: “…all around excellent, resident centred, responsive care. Could not do more…”. Manager stated that she has recently initiated annual reviews with care managers, etc. to ensure that each residents progress is kept under review. The professionals surveyed felt that the home generally communicates well, with one comment being that “…the staff are quick to alert us of any changes in needs…”. Relatives of people living at the home said that they are generally kept well informed about important issues affecting their relative and are “…very Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 15 satisfied…” with the support the home provides. Where asked where they feel the home provides an excellent service one stated: “ …constant, effective care…”. During the inspection the staff were seen liaising with a ‘seizure nurse’ who had visited the home to review the residents current care around epilepsy and provide advice and guidance to the staff. In the care files a log is also maintained of visits by the GP, chiropodist or any other healthcare specialist. In one care file it was noted that one entry for September 2007 stated: ‘blood samples taken’, though there was not reason given for this and this was also not entered in the daily record. Since the last inspection improvements have been made to the medication system and no discrepancies in recording were identified on this occasion. Medication was observe to be stored appropriately. The medication for two residents was looked at and areas needing to be addressed noted as: • • • The home now has a medication disposal bin in the sluice area. Two staff should be present to observe, record and sign for any medication disposed of in the bin. A new thermometer for the medicines fridge must be purchased, as the one in current use is faulty. The form describing why medicines are given must be fully completed. In the records for one resident the ‘medication and what for’ form listed thirteen different medicines prescribed for the resident, though the reason for giving was only entered for one medication. Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. The home needs to improve its procedures for addressing complaints and ensure that the residents are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has an appropriate complaints procedure that provides timescale in which any complaint will be acknowledged and investigated. There has been one complaint since the last inspection, which was received by the CSCI and referred to Roy Kinnear House to investigate and respond to. The complainant contacted the CSCI as they had not received an appropriate response and acknowledgement within the timescales given in the home’s complaint procedure. This was brought to the attention of the manager during the inspection, who was aware of this, and this was addressed by them. The home uses the London Borough of Richmond Protection of Vulnerable Adults Procedure. The staff record indicate that most staff have received recent training in Safeguarding Adults, and training is planned for those who still need to attend this. Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 and 30 Quality in this outcome area is good. The residents live in a pleasant and comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Roy Kinnear House is purpose built, with a lovely, well-maintained sensory garden to the rear of the home. Each resident has their own bedroom that is individually decorated and personalised according to their own preferences. Relatives spoke positively about the environment, with one stating that: “…there is a very kind and homely atmosphere…” The whole house is homely throughout, bright, airy and well-lit. The only aspect that makes the environment un-homely is the nurse station, which is situated in the kitchen area. Consideration should be given to situating this Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 18 somewhere else, particularly as the area is not confidential when staff are talking on the telephone, or writing in residents care records. A domestic staff is employed to maintain the cleanliness of the communal areas and care staff keep the residents rooms clean. The home was cleaned to a good standard on the day of inspection. The pedal bins in the toilets and kitchen areas need replacing as they do not work effectively, and staff have to lift the lid with their hand to dispose of rubbish. Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 and 36 Quality in this outcome area is good. Good recruitment practices ensure that risks to residents are minimised. Improvements need to be made to training and supervision for staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two staff recruitment files were examined, where evidence indicates that appropriate checks are carried out prior to employment, such as a Criminal Records Bureau check, employment history and references sought form previous employers. A job description is also available for all staff roles within the home, and staff have to complete an application form and be interviewed before a job is offered to them. The previous inspection required that all staff receive the necessary training to meet the needs of the residents and that they have regular clinical supervision. The manager has embraced the need for staff to have up-to-date training and has carried out a training analysis to identify gaps in staff knowledge and skills. The manager stated that she is accessing free training available via the Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 20 London Borough of Richmond, though also understood the need to access more specialised nurse training from relevant external agencies. The manager showed evidence that eight staff are due to commence the NVQ level 2 in Care. During the inspection the newest member of staff to Roy Kinnear House was spoken to, where they stated that they felt they received a good induction to the service, having training in fire safety, infection control and moving and handling. Staff training records indicate that most staff have had recent training in food safety, health and safety and infection control. Other core training updates need to be done by all staff in fire safety and moving and handling. Nurses must be kept up-to-date with more specialised training to ensure the residents are receiving relevant and safe care practices. Since the last inspection more regular team meetings have been introduced, such as the fortnightly nurses meeting and monthly team meeting. The manager stated that these are mandatory for staff to attend so that important information can be conveyed to all staff at the same time. One staff member commented that: “…now we started to have a regular staff meeting which are very helpful…”. However, they also added that: “…supervision is not regular…”. At the service the support workers receive one-to-one supervision from the nurses, who in turn are supervised by the deputy manager, who is a nurse. The acting manager receives supervision from the manager, who is not a nurse. The inspector was informed that, until recently a nurse was employed by the company to provide supervision to the deputy manager, but that this had stopped suddenly. It is required that the deputy manager receives regular, consistent supervision from an appropriately qualified nurse to ensure that they are supported in their role. Feedback from staff is that they often work a continuous twelve hour shift, with only a half hour break, where they are unable to leave the service. The Registered Persons should make sure that staff working long shifts are given appropriate breaks that are reflective of the hours they are working. Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 Quality in this outcome area is adequate. There is no Registered Manager at the service, although the temporary manager has a good understanding of where the service needs to improve. This includes their ensuring the health and safety of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is currently no Registered Manager or Registered Person for Roy Kinnear House following the resignations of the previous manager and registered person earlier in the year. Since that time the service has been managed by an agency manager who is at the service 2-3 times a week. The deputy manager has also taken on the role of ‘acting manager’ to provide additional support. The agency manager has a good awareness of areas of improvement needed for the service and will Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 22 provide a short-term form of mentorship to the next permanent manager of the home. The manager stated that the service was in the process of recruiting a new manager. Once in post the manager must submit an application straight away to the CSCI to be registered. The lack of consistent manager to run the service day-to-day was reflected in the feedback received from relatives and staff. When asked where the service could improve one relative said: “…a manager who is at the service and is approachable and listens…”. One staff member also stated that the current management input was “…not sufficient…”. However, another member of staff stated that: “…I think the house is great and run perfectly…”. A staff member also commented that any maintenance issues are: “…reactive…after things have broken or go wrong…”. The service must ensure that an application from a member of the trustees is submitted to the CSCI for them to be the Responsible Person for the company. The service must also ensure that monthly visits, in accordance with Regulation 26 of the Care Homes Regulations 2001 are carried out by a member of the trustees, even in the absence of a Responsible Person. Copies of the report following each visit must be supplied to the CSCI. As identified earlier in the report, record-keeping in the residents daily notes must improve, and a requirement has been made to ensure this area is improved upon. There is regular testing of the fire system and equipment at the service, both by the staff and through external contractors. The staff stated that water temperature checks are carried out when bathing and showering residents, and that the temperatures are not recorded. This is not sufficient and the weekly testing of water from all taps around the home, with an appropriate thermometer must be commenced. A record must be maintained of all temperatures taken. At the time of inspection there were no records available to indicate that Portable Appliance Testing (PAT) or gas safety testing had been carried out in the past year. The five yearly electrical installation certificate was also not available for inspection. Requirements have been made to address this. Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X 2 2 X Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 12(4), 15 Requirement The service must ensure that a person-centred approach is implemented at the service, and that this is used to enhance the care planning and record-keeping. Timescale for action 31/01/08 2. YA12 YA13 16(2)(m)(n) The service must ensure that activities provided take into account the age and all social interests of each resident. This to include residents being involved in daily community activities and shopping. 12(5) The service must ensure that at all times staff communicate verbally with each other and residents in English, unless the care plan for the resident details an alternative language be spoken. The service must ensure that: • Two staff are present to observe, record and sign for any medication disposed of in the medicines disposal bin. • A new thermometer for DS0000038036.V351080.R01.S.doc 31/12/07 3. YA13 31/10/07 4. YA20 13(2) 31/10/07 Roy Kinnear House Version 5.2 Page 25 • the medicines fridge is purchased. The form describing why medicines are given must be fully completed. 31/10/07 5. YA22 22 The service must ensure that complaints are acknowledged within 28 days of receiving the complaint. The service must ensure that the pedal bins are replaced in the bathrooms and kitchen areas. The service must ensure that all staff have up-to-date training in food safety, health and safety, infection control, fire safety and moving and handling. Nurses must be kept up-to-date with more specialised training to ensure the residents are receiving relevant and safe care practices. The service must ensure that the deputy manager receives regular and consistent supervision from an appropriately qualified nurse. All staff must receive a minimum of six one-to-one supervision sessions a year. 6. YA30 30 31/10/07 7. YA35 18(1) 28/02/08 8. YA36 18(2) 31/10/07 9. YA37 9 Once in post, the manager must submit an application to be registered with the CSCI. The Trustees must ensure that an application for a Responsible Person is submitted to the CSCI. The service must ensure that DS0000038036.V351080.R01.S.doc 31/10/07 10. YA37 7 31/10/07 11. YA39 26 31/10/07 Page 26 Roy Kinnear House Version 5.2 monthly visits, in accordance with this regulation are carried out by a member of the trustees, even in the absence of a Responsible Person. Copies of the report following each visit must be supplied to the CSCI. 12. YA41 17 The service must ensure that 31/12/07 staff are trained in good recordkeeping techniques, with particular reference to recording in daily notes of residents. The service must ensure that weekly testing of water from all taps around the home, with an appropriate thermometer, must be commenced. A record must be maintained of all temperatures taken. The service must ensure that up-to-date certificates are available to confirm that PAT testing, gas safety testing and the electrical installation have been carried out within required timescales. 31/10/07 13. YA42 13(4) 14. YA42 13(4) 31/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA17 YA24 Good Practice Recommendations The Registered Persons should consider installing an oven and hob at the service. The Registered Persons should consider re-situating the DS0000038036.V351080.R01.S.doc Version 5.2 Page 27 Roy Kinnear House nurse station to ensure confidentiality. 3. YA31 The Registered Person should make sure that staff working long shifts are given appropriate breaks that they can spend as they wish. Roy Kinnear House DS0000038036.V351080.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Roy Kinnear House DS0000038036.V351080.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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