Care Home: Kenilworth Nursing Home

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What the care home does well Good quality documentation describes the services available within the home to prospective users of the service. The information is available in a number of languages. The operation of the home is focussed around the care needs of the residents, and staff have a detailed knowledge of those needs. Full assessments of residents’ needs are undertaken before a place is offered. Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Detailed care plans are prepared based on the assessments, and these are kept under review. Personal care and health care are given a high priority. Record keeping is very good. Staff and residents have positive relationships, and privacy, dignity and autonomy are well promoted. A wide range of activities, and outings and holidays, are offered. Good quality food, with ethnic choices, is provided. The home has a good atmosphere, and is clean and hygienic. The home is well decorated, well furnished and equipped, safe and has a lovely garden. The staffing levels are high, and the home is fully staffed. All staff are properly recruited, inducted and the training programme is substantial. A very high proportion of the staff are qualified, in either nursing or social care. One to one supervision is undertaken at the required frequency. The home’s complaints procedure is well advertised in a variety of languages. Quality assurance surveys and appropriate health and safety checks are all undertaken. What has improved since the last inspection? The home is now proactive in promoting the use of advocacy arrangements for residents who do not have relatives involved in their care. End of life requests are now included within care plans. The names of residents on their bedroom doors now appear in larger print and are personalised to assist the resident in identifying which room is their’s. The leaking roof has been fixed. All bedrooms have been redecorated and new bedroom furniture has been installed. Bedrooms are more personalised, with more photographs displayed. Corridor carpeting has been replaced and trip hazards within the home have been eliminated. The hot water supply to wash-hand basins and to baths and showers has been improved. The ventilation of bathroom and toilets has been improved by installing new extractor fans. The appearance of bathrooms and toilets has been improved by retiling and reflooring these areas where necessary. Trip hazards within the garden have been reduced, and areas of the garden have been landscaped. New garden furniture has been purchased. Record keeping has improved in that faint and poorly photocopied forms are largely avoided. Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 All staff now wear name badges to assist residents and visitors to identify them. What the care home could do better: It is recommended that the home’s initial admission assessment form is completed prior to admission except for emergency admissions, and in these cases, the form should be completed within one week of admission. It is recommended that all care plans are typed up at the earliest opportunity and that consideration is given to increasing the amount of care plan documentation that is kept on the home’s computer. Key inspection report CARE HOMES FOR OLDER PEOPLE Kenilworth Nursing Home 26/28 Kenilworth Road Ealing London W5 3UH Lead Inspector Robert Bond Key Unannounced Inspection 11:00 8 September 2009 th DS0000010949.V377200.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kenilworth Nursing Home Address 26/28 Kenilworth Road Ealing London W5 3UH 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 8567 1414 020 8567 1052 Mr and Mrs Gopaul Mr Coossialsing Gopaul Care Home 40 Category(ies) of Dementia (40), Mental disorder, excluding registration, with number learning disability or dementia (40), Old age, of places not falling within any other category (40) Kenilworth Nursing Home DS0000010949.V377200.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: Old age, not falling within any other category - Code OP Dementia - Code DE 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 40 2nd September 2008 Date of last inspection Brief Description of the Service: Kenilworth Nursing Home is a 40 bedded Care Home with nursing providing care to older residents within the categories of Mental Health and Dementia. The home, which is situated in a quiet residential area in Ealing, is sited in two formerly separate houses, which have been joined into one building and extended at the rear. Rooms are sited on four levels with a lift connecting the floors. The home has 15 shared double rooms and 10 single rooms. There are three communal areas, varying in size and which are used as lounges and dining areas. There is a large secure garden to the rear of the premises that residents can access. The home is 10 minutes walk from Ealing Broadway where there is a shopping centre and access to bus, tube and rail transport facilities. The current range of accommodation fees at Kenilworth House is from £557 to £1,200 per week. Kenilworth Nursing Home DS0000010949.V377200.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 3 star. This means the people whom use this service experience excellent quality outcomes. This was a key inspection whereby the Care Quality Commission (CQC) inspector assessed the home’s performance against the key National Minimum Standards (NMS) for care homes for older people as published by the Department of Health. The previous key inspection took place on 2nd September 2008 at which time 7 requirements and 2 recommendations were made, and the home was graded as being 2 star, with ‘good’ quality outcomes for residents. Following a complaint from a relative that came to us via the London Borough of Hammersmith and Fulham, we undertook an additional ‘random’ inspection on 18th June 2009 and this led to a further 8 requirements being made, all except one of which concerned the environmental standards of the home. In advance of the current unannounced inspection, the home was sent an Annual Quality Assurance Assessment (AQAA) to complete. We also sent surveys to the residents and staff of the home, and obtained a copy of the London Borough of Ealing’s ‘Provider Review’ of the service dated 8th June 2009 that contained a detailed action plan for the provider to undertake. On the day of this inspection, we spent 4 hours on site during which time we interviewed the whole of the management team, met residents and staff members, toured the whole building, and examined in detail a selection of records and files. Equality and diversity were considered at all times, and examples of good practice are quoted within this report. Quotes are also taken from the surveys we received from residents. On the day of the inspection, the home had more vacancies, three of which were in double rooms. The Manager said his intention was to reduce the use of shared rooms by residents. What the service does well: Good quality documentation describes the services available within the home to prospective users of the service. The information is available in a number of languages. The operation of the home is focussed around the care needs of the residents, and staff have a detailed knowledge of those needs. Full assessments of residents’ needs are undertaken before a place is offered. Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 6 Detailed care plans are prepared based on the assessments, and these are kept under review. Personal care and health care are given a high priority. Record keeping is very good. Staff and residents have positive relationships, and privacy, dignity and autonomy are well promoted. A wide range of activities, and outings and holidays, are offered. Good quality food, with ethnic choices, is provided. The home has a good atmosphere, and is clean and hygienic. The home is well decorated, well furnished and equipped, safe and has a lovely garden. The staffing levels are high, and the home is fully staffed. All staff are properly recruited, inducted and the training programme is substantial. A very high proportion of the staff are qualified, in either nursing or social care. One to one supervision is undertaken at the required frequency. The home’s complaints procedure is well advertised in a variety of languages. Quality assurance surveys and appropriate health and safety checks are all undertaken. What has improved since the last inspection? The home is now proactive in promoting the use of advocacy arrangements for residents who do not have relatives involved in their care. End of life requests are now included within care plans. The names of residents on their bedroom doors now appear in larger print and are personalised to assist the resident in identifying which room is their’s. The leaking roof has been fixed. All bedrooms have been redecorated and new bedroom furniture has been installed. Bedrooms are more personalised, with more photographs displayed. Corridor carpeting has been replaced and trip hazards within the home have been eliminated. The hot water supply to wash-hand basins and to baths and showers has been improved. The ventilation of bathroom and toilets has been improved by installing new extractor fans. The appearance of bathrooms and toilets has been improved by retiling and reflooring these areas where necessary. Trip hazards within the garden have been reduced, and areas of the garden have been landscaped. New garden furniture has been purchased. Record keeping has improved in that faint and poorly photocopied forms are largely avoided. Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 7 All staff now wear name badges to assist residents and visitors to identify them. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Kenilworth Nursing Home DS0000010949.V377200.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 Kenilworth Nursing Home DS0000010949.V377200.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective service users have good quality information about the home, available in a range of languages. The needs of prospective residents are fully assessed before a place is offered, but one of the files we examined only contained the initial assessment information in note form. Intermediate care is not offered by the home. EVIDENCE: We examined the home’s Statement of Purpose and Service Users’ Guide. Both have been kept up to date and contain the current contact details for the CQC. The home’s joint administrator said that these documents can be made available in a range of languages, if required. We examined in detail the care files of two residents who had been recently admitted to the home. Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 10 The resident who had arrived on 17th June 2009 had an ‘initial admission assessment’ undertaken by the home, and supplemented by nutritional, continence, pressure sore and bedrail assessments. The file of the resident who had arrived on 17th August 2009 (that is 3 weeks before this inspection) contained hand written notes of an assessment of needs undertaken by the Manager (but no completed assessment form as such), a risk assessment, nutritional, handling and falls assessments. Both files contained completed Deprivation of Liberty forms and hand written care plans. It is recommended that the home’s initial admission assessment form is completed prior to admission except for emergency admissions, and in these cases, the form should be completed within one week of admission. Kenilworth Nursing Home DS0000010949.V377200.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The resident’s health, personal and social care needs are well set out in individual plans of care, but these would be easier to read if the contents were typed. Residents’ health needs are fully met. Residents are well protected by the home’s policies and procedures for dealing with medicines. Residents are treated with great respect as indicated by the personalisation of bedroom doors and bedrooms that has taken place. Privacy has also been enhanced by new screens for double rooms and reduction in the use of double rooms. EVIDENCE: Both files we examined contained detailed care plans covering a variety of appropriate topics such as challenging behaviour, hygiene, safe environment, mental capacity, eating, and social activity. Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 12 The content of the care plans was handwritten, and a little difficult to read especially as the space on the form was not always sufficient for what the Staff Nurse wanted to write. The Joint Administrator said she would be typing the care plan into the computer, and a recommendation is made concerning this. The care plan format enabled each topic to be separately evaluated and reviewed at least monthly. Care plans were signed by the person creating them, and there was a space for the resident to sign if they were able. The care files contained weight charts that were completed monthly, and body charts that were completed as necessary. One resident spent a lot of time in bed and measures were in place to guard against pressure sores developing. Her partner and family were also involved in decisions about her care. A relative spoke to us by telephone in advance of the inspection and said how pleased she was by the care provided to her brother at Kenilworth. We examined a selection of medication records. The monitored dosage system (MDS) is not used but the medication administration record (MAR chart) system has been replaced with a simpler system than before that is easy to read. No errors or omissions were noted and the medication was tidily stored. It was reported that no controlled medication was currently in use. We toured the home and observed that bedroom doors were kept closed unless the resident was present and wanted the door open. Staff knock on doors before entering. Doors now have larger and personalised names on them, which is commended. Bedrooms now contain more photographs in order to personalise the rooms more. Those rooms that are shared, have new privacy screens provided. A total of 25 surveys were received back from residents, mostly completed with help from a member of staff. The level of satisfaction was high. When asked ‘What does the home do well?’, typical answers were as follows. “Good company, friendship, nice food. Everything is well done. Look after me all the time. Caring for me the way I like it. Friendly environment. Staff are co-operative. My bedroom is always clean, tidy and organised. Providing good care, supporting me to live peacefully”. Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 13 Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents find that the range of activities generally meets their needs. Contact is mostly maintained with friends and relations and the wider community. Residents’ views are ascertained individually and collectively to a good degree. Residents mostly enjoy the food provided which is of a good standard and with choices offered. EVIDENCE: The care plans we examined contained social activity as a separate topic with actions for the staff to undertake to ensure the aims were met. The home has a seven day a week advertised activity programme which is printed with pictures to aid residents’ understanding of it. Staff also organise spontaneous activities. We noted photographs on the wall of a corridor of ‘fruit appreciation mornings’ and flower arranging. We also noted a list of special events and outings that included a BBQ in the home’s lovely garden, an outing to Brighton, and a planned short holiday in Blackpool. Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 15 Religious observance is encouraged in a variety of ways and a variety of religions. Friends and relatives are welcome to visit. Residents’ meetings are held periodically and their choices of activities and food are recorded individually and collectively via care plan reviews and through surveys. The home now has posters up advertising advocacy services that are being used by two residents. We examined the home’s four weekly food menu cycle which is available in a picture format also. We observed the midday lunch being eaten. Residents confirmed to us that they liked the food, and it was clear from what was on their plates that real choice about what to eat did exist. Fresh fruit was seen to be available. Our surveys to residents contained the question, ‘What could the home do better?’ and it was in terms of activities and food that a small degree of dissatisfaction appeared. For example two residents wanted to go out more often, one wanted a holiday, one asked for more parties, two asked for more chapattis, and one asked for more cakes at teatime. But the majority of the feedback was positive with comments such as: ‘The home always arranges activities I can take part in’, and ‘I usually like the meals in the home’. Kenilworth Nursing Home DS0000010949.V377200.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents, their relatives and friends can be confident that any complaints received will be recorded and fully investigated. The translation of the complaints procedure into a variety of languages is commended. A high level of training is provided to staff concerning the Protection of Vulnerable Adults. Accurate and detailed recording is in place for when the home looks after a resident’s own money. EVIDENCE: Each bedroom contains a copy of the home’s complaints procedure which includes the contact details for the CQC. The procedure has been translated into Punjabi, Hindi, French, Italian and Polish, which is commended. Two complaints have been recorded by the home during the last year. One complaint was from a visitor from the Public Guardianship Office concerning an allegation that she saw a bib being snatched off a resident presumably by a member of staff but the identity of the member of staff could not be verified. The other complaint was from a relative of a resident who complained about various environmental issues at the home at the time, and that the resident had a bruises and a cut. This complaint led to a random inspection by the CQC, and an inspection by the London Borough of Ealing (LBE). As a result of action taken following the complaint and the reports produced by CQC and LBE, Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 17 substantial improvements have been made by management to the environmental standards of the home, which are commended. The above complaint, which came via the London Borough of Hammersmith and Fulham who had placed the resident concerned at Kenilworth, also led to a referral being made to LBE’ s Safeguarding of Vulnerable Adults (SOVA) unit, but after an investigation they determined that there was no case to answer. We examined training records that demonstrated that care staff at Kenilworth Nursing Home were being trained in SOVA, the most recent training date having been 3rd September 2009. We examined a sample of the records kept when the home looks after a resident’s money and found the records to be detailed and accurate in that the recorded balance matched the sum of money held. Kenilworth Nursing Home DS0000010949.V377200.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in safe and extremely well maintained environment. Their home is very clean and hygienic and a lovely place to live. EVIDENCE: We toured the property together with the Manager and visited all communal areas, all domestic areas, the garden and almost all of the bedrooms, bathrooms and toilets. We found that every where had been decorated to a high standard. New carpets had been laid in communal areas, and along corridors and on stairs. All trip hazards had been eliminated inside and outside of the home. Some new communal furniture had been purchased for lounges, and for the garden. New bedroom furniture had been provided in almost every room. Bathrooms had Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 19 been retiled where necessary, and new vinyl floors had been laid. The hot water system had been adjusted and a new pump installed upstairs so that every bedroom and toilet and bathroom now had a good supply of hot water. Electric extractor fans had been replaced where necessary so that all were now working. Improvements had been made to the kitchen, and the laundry had been redesigned and re-equipped. The bottom of the garden had been landscaped to make it safe and attractive for residents. The management of the home are commended for the great improvements that have been achieved. No mal-odours were detected, indeed every bedroom was pleasantly scented, which is also commended. The home’s kitchen has been given a 5 star environmental health rating by the London Borough of Ealing. Kenilworth Nursing Home DS0000010949.V377200.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ needs are well met by the high numbers and good skill mix of staff employed, which includes one to one staffing in some instances. The ratio of staff who are qualified is very high. Residents are well protected by the home’s excellent recruitment practices. Staff are well trained and are highly competent to do their jobs. EVIDENCE: We examined the current staff rota. This showed that a minimum of 10 care staff, 2 of whom were nurse trained were on duty each morning, and a minimum of 8 were on duty in the afternoon. Four staff were rostered to be on at night. Additional staff are used where the agreement is for one to one care. The staffing levels exceed the NMS minimum which is commended. The Manager reported that of the 34 carers employed at present, only 2 do not have a nursing or NVQ in care award. Four staff are undertaking level 4 NVQ’s, which is commended. We examined the recruitment files of two staff who have been recently taken on. All appropriate checks have been undertaken, and notes of the interviews are scored and kept, which is commended. Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 21 Two week induction training is provided and the home provides the required mandatory training and maintains records of training undertaken and planned. We sent surveys to staff at the home and received the following comments: “Good staff team spirit. The home is currently improving itself. The home is making a lot of progress in decorating. The home could provide more training in order to keep the staff up to date. They are already doing it but just some extra training in order to train new staff and keep us up to date with any new changes coming.” Kenilworth Nursing Home DS0000010949.V377200.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an excellent management team in place. The home is well run and in the interests of the residents. Residents’ financial interests are well safeguarded. The health, safety and welfare of residents are well promoted and protected. EVIDENCE: The Registered Manager, who is also the Registered Provider together with his wife, has been joined in managing the home by his daughter, who jointly holds the post of Administrator. Together this management team have transferred many aspects of the home making it a more attractive place to live, for which they are commended. Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 23 Quality assurance is maintained by the home annually sending out their own surveys to residents, relatives, visitors and staff members. The results are then analysed and acted upon. We checked the records of money held for one resident, chosen randomly, and found that the record was detailed, and was correct in that the balance shown matched the amount of cash held. In terms of health and safety, the hot water supply has been improved, and trip hazards have been eliminated. We checked that the nurse call bell system worked, and that fridge and freezer operating temperatures were correct. We confirmed that the home had current gas, water and lift safety certificates in place. Over the last year the lift has required attention. Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 24 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 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 4 17 x 18 3 4 x x x x x x 4 STAFFING Standard No Score 27 4 28 4 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x x 3 Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 OP3 Good Practice Recommendations It is recommended that the home’s initial admission assessment form is completed prior to admission except for emergency admissions, and in these cases, the form should be completed within one week of admission. It is recommended that all care plans are typed up at the earliest opportunity, and that consideration is given to extending the extent of care note information that is kept on the home’s computer. 2 OP7 Kenilworth Nursing Home DS0000010949.V377200.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission London region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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