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Inspection on 05/09/08 for The Kensington Nursing Home

Also see our care home review for The Kensington Nursing Home for more information

This inspection was carried out on 5th September 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

We looked at the care assessments and care plans for four residents that require different levels of health and social care. The care plans are in the format of QUEST a new system used by BUPA that does show quite clearly what each resident requires. The four care plans looked at were informative and had all of the relevant up to date information in place that showed reviews take place on a monthly basis or when required if the care plan changes before that time.We spent time talking to staff and looking at training and development records. The staff are happy with the training provided and records show that all staff are up to date with mandatory training. Over 50% of care staff have an NVQ level two or three with four staff currently working towards the qualification. We spent time in all areas of the home including resident`s bedrooms and all communal areas. The Kensington Nursing Home is decorated with fixtures and fittings to a high standard. We spent time talking to residents who told us that they are happy with their bedrooms and that the home was comfortable and homely. We also spent time throughout the day with family and fiends of residents that told us the home was decorated to a high standard and that the aesthetics were good for the resident`s wellbeing.

What has improved since the last inspection?

There was no requirement made from the last site inspection in February 2007.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE The Kensington Nursing Home 40-42 Ladbroke Road London W11 3PH Lead Inspector Jacqueline Derbyshire Unannounced Inspection 5th September 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Kensington Nursing Home Address 40-42 Ladbroke Road London W11 3PH 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) 020 7727 8033 020 77929712 smallc@bupa.com www.bupa.co.uk BUPA Care Homes (GL) Ltd Mrs Christine Small Care Home 53 Category(ies) of Dementia (53), Physical disability (53) registration, with number of places The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with nursing Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Physical Disability Code PD 2. Dementia Code DE The maximum number of service users who can be accommodated is: 53 Date of last inspection Brief Description of the Service: The Kensington Nursing home provides 53 places for people needing residential and nursing care, including 3 places for people needing palliative care. The building comprises of 3 stories, to which there is lift access. All bedrooms are single rooms with en suite facilities. There are various communal rooms, including a pleasant dining room and conservatory on the ground floor, a newly established library and smaller dining and sitting rooms on each floor. The home is decorated with fixtures and fittings of a high standard. The home operates as 3 units, on separate floors, each managed by a senior nurse. The home has attractive, well-maintained gardens to the rear of the building. It is owned and operated by BUPA and located in Notting Hill, close to the tube, shops and services. There are currently forty- seven residents living at The Kensington Nursing home. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Throughout this report the word ‘we’ will be used as meaning the CSCI. This unannounced inspection took place on Thursday 5th September 2008; we spent 9.00 hours visiting the home. The registered manager was not on duty at the time of this site visit and we spent time with the deputy manager, staff, the maintenance officer, assistant chef and people living at The Kensington Nursing Home and lots of family and friends visiting the home. We checked the care records of four people; medication and finance records were looked at and were well recorded. Eight of the bedrooms were looked at and all communal parts of the home including the kitchen, laundry, gardens and dining areas on all floors. The home provides a good standard of accommodation. The home was seen to be clean and tidy. There were forty-seven residents living at The Kensington Nursing Home at the time of this inspection. We received five residents surveys, one professional and fifteen staff surveys; comments from the surveys will be included throughout this report. There are seven new requirements set from this site visit with three good practice recommendations. We will make reference to the Annual Quality Assurance Assessment (AQQA) throughout this report. The weekly charge for The Kensington Nursing Home is £1500. What the service does well: We looked at the care assessments and care plans for four residents that require different levels of health and social care. The care plans are in the format of QUEST a new system used by BUPA that does show quite clearly what each resident requires. The four care plans looked at were informative and had all of the relevant up to date information in place that showed reviews take place on a monthly basis or when required if the care plan changes before that time. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 6 We spent time talking to staff and looking at training and development records. The staff are happy with the training provided and records show that all staff are up to date with mandatory training. Over 50 of care staff have an NVQ level two or three with four staff currently working towards the qualification. We spent time in all areas of the home including resident’s bedrooms and all communal areas. The Kensington Nursing Home is decorated with fixtures and fittings to a high standard. We spent time talking to residents who told us that they are happy with their bedrooms and that the home was comfortable and homely. We also spent time throughout the day with family and fiends of residents that told us the home was decorated to a high standard and that the aesthetics were good for the resident’s wellbeing. What has improved since the last inspection? What they could do better: We looked at the Statement of Purpose that has a lot of outdated information. The Organisation must update the Statement of Purpose to include all of the information in Schedule 1 of the Care Home Regulations 2001. We spent time looking at staff rotas, talking to staff, residents and residents family and friends. There are adequate staffing levels on each floor to provide the personal and health care needs however the levels of staff for providing one to one activities needs to be increased. Staff was seen to be extremely busy on all floors attending to the care requirements of all residents. There are two part time activity coordinators that work on a Monday – Friday and mainly provide group activities. The registered manager must make sure that any frozen food that the packaging has been opened has a date opened and use by date written on the packaging. The packaging should also be resealed to make sure that it is stored safely. We spent time talking to senior nursing staff and discussed the procedure to be followed if there was a safeguarding incident in the home. Senior staff was not familiar with the procedure that must be followed however they stated they would contact the manager or deputy manager who are on call. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 7 We looked at four staff files and checked all of the recruitment records kept by the organisation. The registered manager must check all references are validated for any new staff that are recruited to work at the home. All other recruitment records were in place including a CRB Enhanced Disclosure. The registered manager should also make sure that any copies taken from original documentation has a signature and date to show who checked the original document and when. We looked at the supervision records for four staff and spent time talking to staff. Not all staff are receiving regular structured supervision. The registered manager must make sure that all staff receives regular supervision meetings to make sure that they are meting the aims and objectives of the organisation and their own as written in the Statement of Purpose. We looked at the daily record logs of four residents; some of the entries were very difficult to read. The registered manager must make sure that any records completed by staff are legible as they are important in showing what care has been provided to residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. For people who are self funding and without a Care Management Assessment the assessment is always undertaken by a skilled and experienced member of staff. The assessment is conducted professionally and sensitively and involves the individual, and their family or representative, where appropriate. EVIDENCE: Comments made by the people who use the service and their relatives and friends. ‘I have lived here for many years and I am provided with all of the assistance I require’. ‘I am very happy living here the staff do cater to y every need’. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 10 ‘My mother used to come to The Kensington Nursing Home for respite care and we felt that she was looked after so well that it was right for her to move into the home when she could no longer manage at her own home’. ‘I have been visiting my friend on a daily basis here for a long time and it perfectly suits their needs’. We looked at the home’s statement of purpose that is informative however the document needs to be updated to reflect the care that is provided to all residents. We also looked at a lot of other glossaries and information that would be provided to prospective people looking at using the service. There is also a welcome pack provided to all new residents. We looked at four residents files and all included a contract with the home covering the terms and conditions of the organisation. The deputy manager stated that any resident who was not able to fully understand the contract would be referred to an advocate if no other relatives were known. Information received within the Annual Quality Assurance Assessment (AQQA) completed by the registered manager, indicated that all new prospective residents undergo a pre- admission assessment to make sure that the home can meet all of their needs. We looked at four residents files and all included a full needs assessment using standard assessment tools, including the QUEST care plan, Barthel and Waterlow. The assessments were very informative with all of the relevant information in place. The home does not provide an emergency respite service; admissions take place before 7.00pm to reduce disruption levels for the other residents and respite care is subject to the same assessment process as long-term care. Many of the respite care residents are repeat visitors and therefore familiar with the staff team and daily home routines. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each residents plan; they give a comprehensive overview of their health needs and act as an indicator of change in health requirements. EVIDENCE: Comments made by the people who use the service and their relatives and friends. ‘I am very pleased with the way I am looked after’. ‘I have no problems with the staff they are always courteous and respectful towards me’. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 12 ‘The staff are always very sensitive when caring for my father, they always show the utmost respect’. ‘My friend is a very private person the staff all know this and treat him respectfully’. We looked at four residents’ files the information was very informative showing exactly what care is being provided as written in the initial assessment. The system now being used is QUEST that has all of the relevant areas of healthcare and social care provided and what each resident care need requirements are. Night care plans were seen on each file setting out the residents care at night, including preferred time for going to bed, and for getting up. The deputy manager stated that there are regular audits of care plans and risk assessments. We looked at the risk assessments of four residents and all of the information corresponded with the initial assessment and care plan. We were told by the deputy manager that all residents risk assessments are reviewed along with the care plan on a monthly basis or when required if sooner. All risk areas were seen to work in conjunction with the care plan showing how a risk had been identified with a relevant action plan showing what actions staff was following to minimise the risk to ensure the safety of the resident and staff. Looking at the healthcare records of the four residents all have a GP this may be there own GP or they may have registered with a new GP in the locality. We were told by the deputy manager that she is in discussion with the local surgery to have a GP available to visit the home in emergency situations. Records in each file had entries of when the GP had been to see the resident and the outcome of the visit. We looked at the medication procedures on the three floors; all Medication Administration Records (MAR) were well recorded. The storage of medication was good with the medication rooms having the temperature recorded daily and medication fridges were also checked daily, all records show that the medication is stored at a safe temperature. All Controlled Drugs were checked in the home, all were individually prescribed, we checked the amount against the record and the information recorded was correct. Staff was observed to speak respectfully to residents, using their preferred form of address. The residents privacy is respected, for example staff were seen to knock on the doors of residents before entering and all personal care was attended to in the privacy of the residents own room or in one of the communal bathrooms. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some residents are consulted or listened to regarding the choice of daily activity, but this process could be improved. EVIDENCE: Comments made by the people who use the service and their relatives and friends and staff. ‘I do enjoy the group activities especially the quiz’. ‘I would like to go out for a walk sometimes, unfortunately I have not been out for a while’. ‘We would like for dad to go out in the local community now and again as he was from this area and we know he would enjoy it’. ‘There needs to be more one on one activities unfortunately there are not enough staff on duty’. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 14 ‘I do provide some social time with my key residents unfortunately not enough, as I am so busy looking after their healthcare needs’. We looked at four residents files and care needs assessments. All of the files contained a lot of information regarding the resident’s likes, dislikes, hobbies and leisure interests. We looked at daily activity records for the four residents and there was information written about what activities an individual had done. There are two part time activity coordinators that are responsible for providing all activities. There is a requirement that the organisation look at staffing levels to make sure that all residents are supported daily to participate in activities they enjoy that link into their person centred plan including any aspirations they may have to do activities they enjoy. QUEST is about being person centred and providing an activity not specifically in a group but in one-one sessions if required and doing activities that they value. We were told by the deputy manager that family and visitors are welcome at the Kensington Nursing Home, on the day of the Inspection resident’s families and friends were seen on each floor. We spoke to six relatives and two friends of residents who were very positive about the care provided and stated that the managers and staff made them feel very welcome. We spoke to staff who are positive about their role, however some of the staff did tell us that they have four residents allocated to them as key worker and found it very difficult to spend social time with the residents as they are so busy providing healthcare. Residents were seen participating in a quiz that was set by the activities coordinator. We looked at a plan of all of the activities that are planned in September 2008; the organisation must look at providing a more varied programme including community-based activities. Meals are prepared in the main kitchen and transported to the three floors in trolleys. A hot choice is available at breakfast, lunch and supper when a range of dishes is available. All of the residents spoken with confirmed that they were happy with the food provided, one resident was not so happy with the choice made on the day of this inspection and was very vocal to staff about it. In discussion with the resident we were told that they do not like anything and to not pay any attention to them. We had lunch on one of the floors and all of the choices were tried, the food was very tastefully served and all was of a good quality. We looked at the menus that were varied, nutritiously balanced and were of a good standard. We spent time with the assistant chef who is passionate about what food is provided to residents and told us the menus are planned in advance. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 15 In discussion the assistant chef and deputy manager we were told that any resident that required a special diet or had religious or cultural food requirements would be provided with whatever they wanted. The four files looked at contained a copy of a dietary assessment, with action taken where concerns were identified. We were told by the deputy manager that food and fluid intake is recorded for all residents. There is a requirement that all frozen food that is opened must have a date that it was opened and a use by date on it, the packaging must be resealed for safe storage. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. It is available on request in a number of formats, to help anyone living at, or involved with, the service to complain or make suggestions for improvement. EVIDENCE: Comments made by the people who use the service and their relatives and friends. ‘I am very aware of how to make a complaint if I deemed it necessary’. ‘I would talk to a member of staff if I was not happy about something’. ‘We were given information about how to complain when our mother moved into the home’. ‘I would talk to one of the managers if I had a complaint about the care provided to my relative’. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 17 We looked at the homes complaint procedure that was given to all residents and their families. The complaints procedure is easy to follow and give clear information and timescales for dealing with a complaint. The complaint procedure was also on the notice board in the homes reception area. There have been four complaints recorded in the last twelve months, we looked at all four complaints that had very informative investigation records in place with the outcome of each complaint. We looked at the homes safeguarding policy and procedure that is directly linked to the Royal Borough of Kensington and Chelsea procedure as the commissioning local authority and the ‘No Secrets’ guidance. We were told by the deputy manager that all staff has attended safeguarding training. There has been one protection incident at the home that was still being investigated; we looked at the information in place that showed that the correct procedure had been followed. We spent time with care staff that stated they that they would inform senior staff of any incident. We also spent time talking to senior nursing staff that would at times be left in charge of the home. The nurses told us that they would telephone the manager or deputy manager that are on call if there was a safeguarding incident. The senior staff should be aware of what procedures to follow when an incident may happen in the home informing all of the relevant professionals. We were told by the deputy manager that all senior staff would attend a refresher training session on reporting safeguarding incidents. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 24, 25 and 26. 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 physical environment that is appropriate to the specific needs of the people that live there. The well-maintained environment provides specialist aids and equipment to meet the needs of the people who use the service. The home is a very pleasant, safe place to live. EVIDENCE: Comments made by the people who use the service and their relatives and friends. ‘I am very comfortable living here’. ‘I really like my bedroom, I like to look at my photographs’. ‘The home is very comfortable and homely, my dad is very comfortable’. ‘We bought some of mums furniture to the home that is in her bedroom’. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 19 ‘The home is always clean and tidy, the staff work hard to keep it smelling fresh and clean’. We had a full tour of the home and eight residents rooms were looked at, the standard of decoration and fixtures and fittings is good, one resident’s relative told us that they were consulted with over colour schemes. The residents’ rooms all had personal items including photographs, ornaments and pictures. The residents spoken with were all very happy with their rooms. The floors are all decorated with different colour schemes along corridors, this was done in line with professional input for residents to be able to find their rooms and not get disorientated. There are communal bathrooms on all floors that have specialist equipment in them if required including different types of hoists and baths. All of the residents’ bathrooms have a shower and some residents do prefer a bath. There are dinning rooms/ lounges on all floors that are tastefully done. There is a garden at the rear of the home that has a conservatory looking out onto it. There are rooms available for the hairdresser to use and for any massages or beauty treatments requested by the residents The home has a security system that has cameras outside the building and a monitor is on floors. All visitors have to be given access and sign in and out in the visitor’s book. The home was very clean and tidy on the day of this inspection. We spent time talking to domestic staff who stated that all staff assist in keeping the home clean and tidy and free from any odours. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are adequate qualified, competent and experienced staff to meet the health needs of the people using the service. EVIDENCE: Comments made by the people who use the service and their relatives and friends. ‘ The staff are very competent in what they do I have no complaints they are very kind’. ‘All of the staff are highly skilled and attend a lot of training. I think they do a good job’. ‘The staffing levels at times seem very pushed, I think more staff should be on duty at busy times of the day’. ‘The staffing in the home at times is low and we are extremely busy meeting the residents needs’. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 21 We looked at the staffing rota for all floors; the staffing levels are adequate and are meting the healthcare needs of all residents. We were told by the deputy manager if a care package changed and more input was required this would be dealt with immediately. As written in this report the organisation must look at the staffing levels for providing social care activities to all residents. We looked at four staff files; the recruitment of new staff is co-ordinated by the registered manager. All relevant checks were seen to be in place including CRB’s on all staff and pin numbers were up to date on nurses. All copies of original documentation seen did not have a date and signature showing that original documents had been seen. A copy of all original qualifications and training is kept on the staff file. Looking at the references in the four staff files the references had not been checked for validity. We were told by the deputy manager that this is not part of the recruitment procedure however she will make sure that all references are checked before any new member of staff is employed. We looked at the training and development records of all staff, there an intense induction training covering all mandatory training but also specialised training including Dementia Awareness, Protection of Vulnerable Adults, Palliative Care and a lot more. We were told by staff that they thoroughly enjoyed the training and appreciated the support from the managers in allowing them the time to participate in the training. There are 14 nurses employed including the deputy manager and head of nursing. We were told by nurses that they attended the full induction training and are nominated by the manager to attend specialist training. All care staff spoken with was positive about their roles in the organisation, there are currently 25 care staff including regular bank staff. Fifteen staff has an NVQ or above, there is four more staff working towards the NVQ qualification. There is a training programme in place and the managers nominate staff to attend as required. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the required qualifications and experience and is competent to run the home. EVIDENCE: Comments made by the people who use the service and their relatives and friends. ‘The manager and deputy manager are always available to talk to in regard the care of my mother’. ‘The manager will always listen to what we want and implement any changes’. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 23 The registered manager is a qualified RGN nurse and has an NVQ level 4 in Management. The registered manager has been in post for over three years and has the relevant experience to run the home. The registered manager was on annual leave at the time of this unannounced site inspection, we spent time with the deputy manager who was very knowledgeable about all procedures and provided us with all of the information required. We were told by the deputy manager that all residents are liaised with on a regular basis to make sure they are happy with the care and support provided at the home. There is a quality assurance procedure that is followed by all BUPA providers and all residents will attend regular reviews with relevant professionals and family included if required. We were told by the deputy manager that all information received will be actioned and improvements will be made in any area that is required. We were told by the manager that a residents and relatives forum happens on a regular basis this is invaluable to getting information directly. We looked at quality assurance audit records that had action plans in place for any areas that required improvement. We looked at the finances of eight residents, all records were correct showing what had been purchased with receipts in place. All residents finances kept by the home are put into a bank account that each resident has` a specific code for. All interest is paid to all residents depending on the amount they have in the account. The balance of money kept in the safe for residents was correct. The residents are encouraged to keep their own money, as there are lockable draws in each room. This is requested by relatives to keep money for residents if they need to purchase any toiletries or to get their hair done by the hairdresser. We spent time talking with staff and looking at supervision records, not all staff are receiving regular structured supervision meetings. The registered manager must make sure that all staff receives the relevant amount of supervision sessions depending on their contracted hours. We looked at records kept by the home that are locked away in lockable storage cabinets. All records looked at were up to date however some daily records completed by staff were difficult to understand, the registered manager must make sure that all records are legible with the relevant information in place. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 24 We spent time with the maintenance officer and looked at all health and safety records including fire safety, water temperatures, safe water checks (legionella), and maintenance records, all records were well recorded and up to date. The maintenance officer told us he does daily and weekly checks in most areas. All staff is fully trained in infection control, the home has a strict admissions criteria and no individuals are admitted with any infectious disease that could have a health impact on other residents living at the home. All staff has completed moving and handling and is familiar with the equipment in the home. The AQQA had all of the information on health and safety showing that the home is a safe environment for people to live and work. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 3 3 STAFFING Standard No Score 27 X 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 2 3 The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation Schedule 1 Requirement The Organisation must update the Statement of Purpose to include all up to date relevant information to inform prospective people of the aims and objectives of the organisation. The registered manager must make sure that there are sufficient staff on duty to provide all residents with activities of their choice to make sure that there aims and aspirations are being met. The registered manager must make sure that any frozen food that the packaging has been opened has a date opened and use by date written on the packaging. The packaging should also be resealed to make sure that it is stored safely. The registered manager to make sure that all senior staff that are left in charge of the home are up to date with the procedure to follow if a safeguarding incident occurs to make sure all relevant professionals are contacted. DS0000026016.V367846.R01.S.doc Timescale for action 04/12/08 2 OP12 OP27 18 04/12/08 3 OP15 16 11/09/08 4 OP18 13 04/10/08 The Kensington Nursing Home Version 5.2 Page 27 5 OP29 19 6 OP36 18 7 OP37 17 The registered manager to make sure that all references are validated before any new staff are recruited to work at the home to make sure all residents are safeguarded. The registered manager to make sure that all staff receives regular structured supervision meetings including bank staff that are used on a regular basis. To make sure that they are meting the aims and objectives of the organisation as written in the Statement of Purpose. The registered manager must make sure that any records completed by staff are legible as they are important in showing what care has been provided to residents. 04/10/08 04/12/08 04/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard OP18 OP27 OP28 Good Practice Recommendations The registered manager to set up a safeguarding folder with the procedure in for staff to follow. The registered manager to make sure that the key to staff shifts on the night shift rota shows all three floors. The registered manager to make sure that any copies taken from original documentation as part of the recruitment procedure has a signature and date to show who checked the original document and when. The Kensington Nursing Home DS0000026016.V367846.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Kensington Nursing Home DS0000026016.V367846.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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