Care Home: Kingsley House Nursing Home

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What the care home does well The home has a good system in place for assessing the needs of potential residents, planning their care and working to meet their health and personal care needs. There is an excellent and proactive approach to the care of residents who are dying. The home provides activities that enable residents to maintain contacts with the local community and has a positive approach to the use of advocates to represent resident`s views.Varied meals are provided that are clearly enjoyed by residents and their relatives. The availability of the complaints procedure ensures that information is available should any complaint be raised by residents or on their behalf by relatives. In addition staff are trained in how to deal with any potential abuse issues. The home was generally well-maintained and clean providing residents with a safe and comfortable environment. A range of training is provided for staff and the recruitment is based upon robust procedures. The home is well managed and there is good quality assurance based on collecting the views of residents and their representatives about the service. What has improved since the last inspection? Reviews of care plans with residents or their relatives had been taking place. Medication such as creams had been dated on opening as a guide to their expiry date. Waste bins with lids have been provided in the interests of improved infection control procedures. There had been monthly unannounced visits to the home by the registered provider with reports produced. What the care home could do better: Some improvements are needed to handwritten entries on medication administration charts. More care staff should undertake NVQ training. A risk assessment should be completed for Legionella and checks need to be carried out to ensure that cleaning materials are kept in correctly labelled containers. CARE HOMES FOR OLDER PEOPLE Kingsley House Nursing Home Gumstool Hill Tetbury Glos GL8 8DG Lead Inspector Mr Adam Parker Unannounced Inspection 7th October 2008 08:15 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 Kingsley House Nursing Home DS0000016486.V373313.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. Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsley House Nursing Home Address Gumstool Hill Tetbury Glos GL8 8DG 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) 01666 503333 01666 503318 The Cotswold Nursing Home Company Limited Mrs Barbara Jean Harpwood Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability (1) of places Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named Service User under 65 years of age Date of last inspection 9th October 2006 Brief Description of the Service: Kingsley House is a care home providing nursing care for thirty-three older people. The property is an historic eighteenth century building, which has been converted and adapted for its current purpose. Service users accommodation is provided on four floors, all of which are accessible by stairs and shaft lifts. A large number of residents are accommodated in shared rooms, with thirteen single rooms available. Some rooms provide en-suite facilities, or there are communal bathrooms that provide assisted bathing facilities and toilet facilities conveniently situated around the home. Each room has its own wash hand basin. Large lounges are situated on the first and ground floors, and a dining room and conservatory are also available on the ground floor. Information about the service to include CSCI reports is made available by the provider to prospective service users through the homes’ Statement of Purpose and Service Users Guide. At the time of inspection the fees were £428 to £680 per week. Additional charges are made for hairdressing, toiletries, chiropody, newspapers at cost and transport. Kingsley House Nursing Home DS0000016486.V373313.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 stars. This means the people who use this service experience excellent quality outcomes. The inspection visit was carried out by one inspector on one day in October 2008. The registered manager and the responsible individual were present for the inspection visit that consisted of a tour of the premises and examination of residents’ care files. In addition staff recruitment and training was looked at as well as documents relating to the management and safe running of the home. A sample of residents were selected for inspection against a number of outcome areas as a ‘case tracking’ exercise. Survey forms were received from residents, their relatives, General Practitioners (GP) and staff working at the home. Three residents and one visitor were spoken to during the inspection visit. We requested an Annual Quality Assurance Assessment (AQAA) from the home and although this was provided after the inspection visit it was comprehensive and gave us the information we asked for. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: The home has a good system in place for assessing the needs of potential residents, planning their care and working to meet their health and personal care needs. There is an excellent and proactive approach to the care of residents who are dying. The home provides activities that enable residents to maintain contacts with the local community and has a positive approach to the use of advocates to represent resident’s views. Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 6 Varied meals are provided that are clearly enjoyed by residents and their relatives. The availability of the complaints procedure ensures that information is available should any complaint be raised by residents or on their behalf by relatives. In addition staff are trained in how to deal with any potential abuse issues. The home was generally well-maintained and clean providing residents with a safe and comfortable environment. A range of training is provided for staff and the recruitment is based upon robust procedures. The home is well managed and there is good quality assurance based on collecting the views of residents and their representatives about the service. 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 7 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 Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 8 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s admission procedure ensures that all residents are admitted on the basis of a full assessment of their needs, so that they can receive the care that they require. EVIDENCE: The documentation for a person who was due to be admitted to the home but had already been assessed was looked at. The person was coming into Kingsley House from another care home and copies of assessments and care plans produced by the home had been obtained. In addition a copy of the care plan produced by the local authority funding the care had also been obtained. It was noted that the registered manager was taking care to provide an individual room suitable for the needs of the new resident when they arrived. The home does not provide intermediate care and so Standard 6 does not apply. Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 9 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): 7,8,9,10 & 11 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home works well to meet residents’ health and personal care needs and upholding their privacy and dignity. In addition there is an excellent approach to caring for residents at the time of their death. EVIDENCE: A number of residents care plans were examined. These were detailed and described specific needs and how these would be met through interventions. It was notable that where appropriate the care plans aimed to promote any aspect of independence that the resident may have. Formal reviews of care plans had been undertaken and with one resident, the documentation described how the review had taken place in the company of the resident. The registered manager stated that resident’s relatives would also be involved in some care plan reviews. Where a need was identified, residents had psychological care plans completed. A detailed daily record is maintained for each resident this recorded such information as when wound dressings had been changed. Two residents had Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 10 been receiving input from mental health services. There was no documentation on file relating to the Care Programme Approach (CPA) to check if the resident’s care plan was in line with this. The home should find out if arrangements are in place under the CPA and if so request a copy of related documents and request involvement in any future review meetings. Both of the residents who returned survey forms indicated that they always received the care and support they needed. Risk assessments had been completed for pressure area care and moving and handling. Skin condition assessments were being carried out and residents were being weighed as to their assessed needs. There was recorded evidence of residents receiving input for their health needs from visiting professionals such as district nurses, chiropodists and audiologists. In addition a separate record had been made of input from GPs and Consultants. Wound assessment charts were in place for some residents, these were detailed and had been kept up to date. The homes’ AQAA document described how the home had been involved in a research study for the development of a new type of wound dressing with apparently positive results for one resident. The arrangements for medication storage, administration and recording were checked. Medication was stored securely in the small treatment room; the registered manager described how medication would be moved to a new larger room when work was complete. The temperature in the treatment room had been monitored and recorded. Some higher than normal temperatures had been recorded in the summer. Containers for liquid medication and eye drops containers had been dated on opening as an indication of the expiry date. Medication administration records (MAR) had no gaps in recording and any hand written entries generally had two staff signatures and had been dated. However it was noted that some handwritten changes to directions had not been signed, these should be treated in the same way as written directions with signing and dating and an indication that a second member of staff has checked the change. Codes had been used to clarify any occasion when medication had not been administered. The recording of the administration of controlled drugs was looked at and this was found to be in good order. Where controlled medication had been given for pain relief, administration had been at consistent times in the interests of pain management. A pain assessment charts had been completed for one resident and this was being used in conjunction with the MAR. A domestic remedies list was in place that had been signed on an annual basis by GPs. Both GPs who returned surveys indicated that medication was appropriately managed at the home. Residents confirmed that staff knocked on doors before entering and were polite to them. Shared rooms were equipped with screening curtains between Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 11 beds as an aid to promoting privacy and dignity. One relative commented about the care given to a resident in the home that their “ dignity was never compromised.” The home places a great emphasis on providing a good quality of ‘end of life’ care. Where appropriate residents have ‘end of life’ care plans drawn up which are presented on different coloured paper to other care plans for easy reference by staff and to highlight their importance. The home had taken part in a pilot scheme for the introduction of ‘end of life’ care and had been using the Liverpool Care Pathway approach to providing care in this area. Each year an event is held in the home to remember those residents who have died with relatives invited and a Christian service conducted by a local Minister. Photographs of the previous years event were seen during the inspection visit. The registered manager and the deputy matron had produced an abstract article entitled “A way of remembering” about the reactions of staff to the deaths of residents in the home. A number of staff had undergone training in palliative care. We received a letter from a relative of a resident who had died in the home and they praised the way that the resident had been cared for during their final days in the home. Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 12 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): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home takes an active role in encouraging resident’s contact with family, friends and parts of the local community providing a good degree of social contact. In addition residents receive a choice of varied and nutritious meals. EVIDENCE: The home has an activities coordinator and a range of activities are on offer to residents such as entertainment provide in the home, trips out into to the town and visits to local attractions. Destinations had included a day out to the seaside, a visit to a local sheep farm and visits to a garden centre for tea. One resident spoken to during the inspection visit described how they had taken part in quizzes and had been making Christmas cards. The home’s AQAA document stated that activity sessions were provided twice a week and residents are consulted about the destinations of trips out. Holy Communion is held in the home on a monthly basis. Survey forms received from relatives of residents contained positive comments about how they were welcomed into the home when they visited. One Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 13 commented, “ They make me feel very welcome always readily bringing cups of tea.” One visitor spoken to during the inspection visit described how she was able to book a meal the day before she visited so that she could eat lunch with the resident she was visiting. Another relative was very positive about the fact that the residents she visited had a telephone in their room as an aid to maintaining contact. Contacts had been maintained with the local community through regular visits to Tetbury. One resident had been attending a local day centre and a group of residents had attended a pantomime in the town in the past. Information about advocacy services is available in the home and the home’s AQAA document described how arrangements had been made for an advocate to visit the home to represent one resident. Additionaly advocates had visited the home to give a talk. Residents are able to personalise their individual rooms with a number of items including furniture. The menu changes on a four weekly basis. There was a cooked lunch with soup or a cooked snack for supper. Lunch was briefly observed in the new dining room on the ground floor where a number of residents were eating. Staff were giving assistance where required. Some residents were taking their meals in their individual rooms. Meals were covered prior to serving to maintain warmth. Residents who took their meals in a pureed form had these presented with individual portions of the meal pureed separately. Although records had been kept of the dietary intake of residents where there were concerns, there was no system for recording any special diets that may be provided and this needs to be given consideration. During the inspection visit one resident described the meals provided as “ very good.” Another described the meals as “good quality” and praised the variety of the meals. In addition a visitor also commented on the “wonderful food.” On admission the food likes and dislikes of residents are recorded for future reference. Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 14 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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available if any resident or their representative should wish to make a complaint and the staff training should ensure that residents’ legal rights are upheld and they are protected from abuse. EVIDENCE: The home has a complaints procedure that is included in the service users guide, which is given to residents and their relatives when the resident is admitted to the home. The home had not received any complaints since the previous inspection in 2006. Both of the residents who returned survey forms indicated that they knew how to make a complaint, as did all except two of the relatives who returned surveys. In relation to resident’s legal rights, the home has information on the Mental Capacity Act 2005 available on all units and training has been provided for staff The home has a policy for protecting residents from abuse as well as a ‘whistle blowing’ policy. Training in protecting residents from abuse has been given to the majority of staff employed in the home. In addition the deputy manager has undergone enhanced training in adult protection. Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 15 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): 19,24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the benefit of living in a well-maintained and clean, environment with personalised individual rooms. EVIDENCE: A tour of the premises was undertaken. All areas of the home inspected were found to be clean, well maintained and decorated and smelt fresh throughout. Improvements had been made to a number of areas such as the kitchen and two bathrooms. At the rear of the room there were patio gardens that residents could access in good weather. There were communal areas on the ground and first floor. At the rear of the ground floor an extension was in the process of being completed. Part of this extension was a new dining room that had been brought into use. Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 16 In the entrance hall there was information displayed about the home and notices about entertainment and meetings. Residents’ rooms were comfortable and contained various degrees of personalisation. The laundry, situated in the basement was due to be relocated to the new extension. Since the previous inspection waste bins with lids had been provided in the interests of improved infection control procedures. Both of the residents who returned survey forms indicated that the home was always fresh and clean. Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 17 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): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff are deployed and training is undertaken in a number of areas to meet residents needs with robust recruitment practices in place. EVIDENCE: At the time of the inspection visit, staffing in the home was one registered nurse on duty during the day with six care staff in the morning and four in the afternoon. At night there was one qualified nurse and two care assistants on duty. Ancillary staff in the home consisted of a cook, a kitchen assistant, and two cleaners. Out of 19 care staff there were five who had achieved an NVQ at level two with a further three staff having achieved a level three. Three care staff were working towards an NVQ level three. Records for recently recruited members of staff were examined. All the required information and documentation had been obtained including an employment history against which any gaps in employment could be explored. Checks against the Protection of Vulnerable Adults list were being made as well as with the Criminal Records Bureau. In addition the home was making the correct checks on the registration status of any registered nurses employed. Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 18 The home was providing induction training for new staff in line with the nationally recognised Common Induction Standards. This has been developed using ‘E –learning’ where staff use information technology to undergo induction. The system allows for progress to be checked by management. In addition the home has undergone audits from two universities to provide placements for nursing students. English lessons have also been provided by the home to a number of overseas staff. On a survey form one GP mentioned “ Caring, compassionate, efficient staff who provide a high standard of care to all their residents.” All of the surveys received from staff gave positive indications about the training they had received. Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 19 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): 31,33,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed with consultation with residents about the service. Although safety checks are in place, some further attention is needed to two areas to ensure residents safety and well being. EVIDENCE: The registered manager has worked at the home for a number of years; she is a registered nurse and has achieved the registered manager’s award. She has also achieved a diploma in counselling and recently completed a course in teaching, assessing and mentorship. The home uses an annual residents’ questionnaire for checking the quality of the service provided in the home. This is also sent out to relatives. Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 20 The questionnaire covers nutrition, the home environment, care and communication. When completed questionnaires are audited and a document is produced stating the homes response to any areas where residents indicated any areas for improvement. Examination of the audit document for 2007 showed how the home had addressed two issues that had been raised regarding the serving of meals. Unannounced visits are made to the home by the responsible individual under regulation 26. Copies of reports of these visits are held in the home and were viewed during the inspection. In addition a suggestion box is provided for staff to raise subjects for discussion at staff meetings. The registered manager also described how regular checks were made on care plans. The arrangements for looking after residents’ money were looked at. Secure storage was available and a check on the money held for one person showed this to be accurate in relation to the records kept. Each resident had a clear plastic wallet, which was a useful way of checking the amount held. Staff had received training in safe working practices in the areas of fire safety, infection control, food hygiene and moving and handling. One relative of a resident described on a survey form “any moving and handling is done quietly and skilfully using all the aids provided.” Weekly checks are made on hot water temperatures with records kept. Central heating boilers had been recently installed and so had yet to receive an annual service. The electrical wiring in the home had been checked in 2004 with a satisfactory result. Portable electrical appliances had been checked in September 2007 and checks were due to be repeated. The two passenger lifts had been serviced in 2008. Hoists and wheelchairs had also undergone servicing and maintenance checks. The home has completed a fire risk assessment although has not had a recent inspection from the fire safety officer. The fire risk assessment and evacuation procedure was not checked during the inspection visit. The kitchen has had an inspection from the environmental health department of the local authority and has achieved a four star rating. Window restrictors are fitted to upper floor windows. A security risk assessment had been completed for the premises. A discussion was held regarding the risk of Legionella in the home. A risk assessment should be completed to establish the level of risk. The home keeps a record of accidents and this is audited on a three monthly basis to examine any patterns or trends in the occurrence of accidents. It was noted that some cleaning materials including bleach on the two cleaning trolleys had been decanted into containers that were not adequately labelled. Checks should be made to ensure that correctly labelled containers are used to store all cleaning materials so that information is readily available in the event of any unwarranted contact by residents. Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 21 Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 2 Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 23 No 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. Standard Regulation Requirement Timescale for action No Requirements. 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 OP7 Good Practice Recommendations The home should check if arrangements are in place under the Care Programme Approach for any residents and if so obtain a copy of related documents and request involvement in any future review meetings. The practice of signing and dating handwritten directions on the medication administration charts should also be used when any medication is stopped and the chart is marked accordingly or when any changes are made to the chart. A record should be kept of any special diets provided for residents. More care staff should undertake NVQ training. A risk assessment for Legionella should be completed taking into account guidelines from the Health and Safety Executive. Checks should be made to ensure that all cleaning materials are kept in correctly labelled containers. DS0000016486.V373313.R01.S.doc Version 5.2 Page 24 2. OP9 3. 4. 5. 6. OP15 OP28 OP38 OP38 Kingsley House Nursing Home Kingsley House Nursing Home DS0000016486.V373313.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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