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Kestrel Grove Nursing Home
Hive Road
Bushey Heath
Herts
WD2 1JQ
The Commission for Social Care Inspection aims to: • Put the people who use social care first • Improve services and stamp out bad practice • Practise what we preach in our own organisation Reader Information Document Purpose Inspection Report Author CSCI Audience General Further copies from 0870 240 7535 (telephone order line) Copyright 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 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.

SERVICE INFORMATION
Name of service
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)
Category(ies) of
Old age, not falling within any other category registration, with number (57)
of places

SERVICE INFORMATION
Conditions of registration:
A maximum of 32 persons requiring nursing care and a maximum of 25 persons requiring personal care may be accommodated at any one time. Date of last inspection
Brief Description of the Service:
Kestrel Grove is a private nursing home situated in a quiet residential area of Bushey Heath, Hertfordshire. Bus, public transport facilities are accessible within a few minutes walk from the care home. The care home has a large car park at the front of the home for in excess of 20 cars. Shopping facilities and local amenities are situated in Bushey Heath Village, a short drive away. The home consists of a large, older house with two extensions, one on either side, in well-maintained grounds of about 6 acres. The extensions/wings have been constructed at different periods of time. The newest wing is found to the left of the main building and provides accommodation mainly for people using the service with personal care needs. The main house and part of the wing on the right are served by a shaft lift, while the wing on the left is served by a chair lift. The remaining part of the home is for the accommodation of people using the service requiring either nursing or personal care. The home is registered for 32 people using the service requiring nursing care and 25 service users needing personal care. Accommodation is provided in single rooms situated mostly on two levels. People using the service share a number of communal areas. There is a main lounge and dining area in the main house and another lounge in the new wing. Mrs Kathleen Sweeney-Meacock manages the home with support from the proprietor Mr Paul Tripp. Information about the fees are accessible from the provider and/or from the website. This is an overview of what the inspector found during the inspection.
This unannounced key inspection took place during November 2007 and lasted
over two days.
The registered manager and registered provider were available on both days of
this key inspection.
I spoke to people using the service, relatives, staff, a visiting National
Vocational Qualification in care assessor during this key inspection.
The home sent a very detailed Annual Quality Assurance Assessment back to
the Commission for Social Care Inspection within the given timescale.
I viewed care plans and other records and documents necessary to make a
judgement about the quality of care provided to people using the service.
The home has four units, I case tracked people using the service in each of
these units.
I would like to take the opportunity thanking everybody involved and
supporting me during this unannounced key inspection.
What the service does well:

This is a very well run and managed care home with nursing.
Staffing ratios are very high and people using the service have to wait rarely
for support.
All family members spoken to have been very positive about the care home
and the care provided to people using the service.
Care plans are of very good standard and are reviewed and up dated regularly.
Statement of purpose and service users guide are easily available and of very
good quality.
People using the service told me that the food is excellent and menus showed
that the home is providing three roasts per week.
The home is nicely decorated and has domestic furniture for people using the
service to use.

The registered manager is very knowledgeable and enthusiastic in working
with the elderly.
What has improved since the last inspection?

The home has met four of the five requirements made during the previous
inspection. The registered manager informed me during writing of this report
that she has met the repeat requirement made during this inspection.
The home has purchased a portable stair lift, which allows people using the
service to access communal areas without leaving the building.
The home has undertaken ongoing maintenance and repairs of the premises.
What they could do better:

I have made three requirements during this key inspection.
The alarm button of the lift was not working and people using the service are
not able to alert staff when stuck in the lift, this must be addressed.
I noted that the gate to the staff room was open and unlocked, which could
lead to people using the service falling down the stairs and I informed the
registered manager that the home must ensure to keep the gate locked at all
times.
The registered manager has started to supervise staff and delegated
supervisions to senior staff. The minimum required number of six supervisions
per year was however not met; this is required.
Please contact the provider for advice of actions taken in response to this
inspection.
The report of this inspection is available from [email protected] or by
contacting your local CSCI office. The summary of this inspection report can
be made available in other formats on request.

DETAILS OF INSPECTOR FINDINGS

CONTENTS
Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Management and Administration (Standards 31-38) Statutory Requirements Identified During the Inspection
Choice of Home

The intended outcomes for Standards 1 – 6 are:
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):

People using the service experience excellent outcomes in this area.
This judgement has been made using available evidence including a visit to
this service.
Prospective people using the service and their families are treated as
individuals and with dignity and respect for the life changing decisions they
need to make. The home has developed a comprehensive Statement of
Purpose and Service User Guide, which is very specific to the resident group
and considers the different styles of accommodation, support, treatment,
philosophies and specialist services required to meet the needs of people who
use services. All new people using the service receive a full comprehensive
needs assessment before admission, this is carried out by staff with skill and
sensitivity.
EVIDENCE:

Prospective people using the service and others have access to information
about the service provided by the care home. This is provided in from the care
home’s website or in paper documentation. A detailed service users guide and
statement of purpose is available in the care home and on the care homes
website. Both documents are specific to the care provided by the home and are regularly updated. I have case tracked four people using the service and viewed their assessment records. All records showed a detailed assessment undertaken by the registered manager. It was also evident that information collated during the assessment process has been incorporated in the care plan. People using the service or their representatives signed assessments. People using the service and family members spoken to tell me that they know about the assessments and that they have been involved in the process. The home does not provide intermediate care; National Minimum Standards 6 is not applicable.
Health and Personal Care


The intended outcomes for Standards 7 – 11 are:
7.
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):

People using the service experience excellent outcomes in this area.
This judgement has been made using available evidence including a visit to
this service.
Staff are fully committed in supporting individuals to lead purposeful and
fulfilling lives as independently as possible. The care plan is developed with,
and owned by, the individual, based on a full and up to date holistic
assessment. The home has an efficient medication policy supported by
procedures and practice guidance, which staff understand and follow. The
home has a good record of compliance with the receipt, administration,
safekeeping, and disposal of Controlled Drugs.
EVIDENCE:

I have assessed four care plans in detail during this key inspection. All care
plans have been of very good quality and have been reviewed together with
the person and or their representative. Care plans provide good information of
care needs and how to support people holistically. People using the service
have falls assessments in place as required by National Minimum Standards.
Previous inspections required to provide detailed bedrail assessments, this was still found to be outstanding during this key inspection. The registered manager contacted me after this inspection informing me that she has undertaken the required bedrail assessments. A registered nurse manages the home and a registered nurse is available on all shifts. During this key inspection one of the people using the service had a Grade 3 pressure sore, which is dealt with appropriately by the home. The home is monitoring peoples weight and staff have guidelines in place in regards to positioning people with pressure sores. The home is involving dieticians, tissue viability nurses, if outside the expertise and knowledge of nursing and care staff employed by the home. I observed people using the service having an exercise session during this inspection and falls are recorded and reported to the Commission for Social Care Inspection. People using the service who are at risk of falling have a falls assessment in place. People using the service are registered with their General Practitioner and visiting opticians, dentists and chiropodists are available for people using the service. I have assessed medicines storage on each unit. Medicines are stored in lockable cabinets in the medicines room, which can be locked from the outside; the key was with the shift leader. Controlled drugs are stored, administered and recorded as stated and required by the Royal Pharmaceutical Society Guidance. Medication is dispensed from a local pharmacist. Medication Administration Sheet had no gaps and medication records are of good standard. Medication is only administered by Registered Nurses. People using the service spoken to were very complementary about the home and the care provided by staff. Mail is given to people using the service unopened and people using the service informed me that they wear their own clothes. People using the service told me that they are treated with dignity and respect from care staff, manager and provider. One person told me that they could see their General Practitioner in their room. The home has no double rooms.
Daily Life and Social Activities


The intended outcomes for Standards 12 - 15 are:
12.
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):

People using the service experience excellent outcomes in this area.
This judgement has been made using available evidence including a visit to
this service.
People who use services are able to enjoy a full and stimulating lifestyle with a
variety of options to choose from. The routines, activities and plans are
resident focused, regularly reviewed, and can be quickly changed to meet
individuals changing needs, choices and wishes.
Meals are very well balanced and highly nutritional and cater for varying
cultural and dietary needs of the people who use services.
For those individuals who need support during mealtimes, including those who
have swallowing or chewing difficulty staff give assistance.
EVIDENCE:

Likes and dislikes are recorded in care plans. The home has an activity co-
ordinator employed. The weekly activity programme is displayed in different
areas within the home. Records of activities show Film night, Bingo, Exercise,
Entertainment and Happy Hour. During the day of this inspection an
entertainer visited the home and a large number of people using the service
attended this. One person using the service told me that during Happy Hour
residents get dressed up and meet up for some drink and snacks in one of the
lounges of the home. He said, “I love the Happy Hour very much”. Another
person using the service told me that the home had a special Halloween night, which was a lot of fun. The home is celebrating Jewish Festivals such as Sabbaths, Chanukah, Purim, etc. A local rabbi as well as a Roman Catholic Priest visits the home regularly. People using the service informed me that the home is organising Barbeques in the summer and I have seen trips to shopping centres advertised on notice boards throughout the home. People using the service informed me that family members can come and visit whenever they want, this was confirmed by two relatives I have spoken to during this inspection. Relatives informed me that they are very happy about the care provided, and the way the home communicates with them. The home has an annual Carroll concert and is visited by the local Brownies for Christmas. Finances are handled by people using the service independently, their relatives or the Court of Protection. The home is not handling any finances for people using the service. The home invoices people using the service monthly with any expenditure for clothes, toiletries, hairdressing, chiropody, etc. People using the service invited me to see their room and it was evident that they are able to bring personal possessions when moving in. All people using the service spoken to told me that they liked the food very much. The menu is varied and three roasts are provided during the week. People using the service are asked daily of their meal choice. The registered provider invited me to sample a meal, which was well prepared and very tasty. Special food requests can be met and the home has special arrangements with two delicatessen shops and a local kosher butcher. I observed meal times, which were unrushed and enough staff were on duty to support people who need help with feeding. The home is meeting specialist dietary requirements such as peg feeds, pureed diets, diabetic food, etc.
Complaints and Protection


The intended outcomes for Standards 16 - 18 are:
16.
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.
The Commission considers Standards 16 and 18 the key standards to
be.
JUDGEMENT – we looked at outcomes for the following standard(s):
People using the service experience good outcomes in this area.
This judgement has been made using available evidence including a visit to
this service.
The home has an open culture that allows residents to express their views, and
concerns in a safe and understanding environment. The service has a
complaints procedure that is clearly written and easy to understand. The
policies and procedures for Safeguarding Adults are available and give clear
specific guidance to those using them.
EVIDENCE:

The home has a complaints policy in place, which is compliant with National
Minimum Standards. Policies have been reviewed in September 2007. The
complaints policy can be accessed in the service users guide and on the homes
website. The home has received three complaints in the past year; one of
these complaints was external. Complaints have been recorded and
investigated appropriately. People using the service informed me that they
would complain to the registered manager or provider if they had a problem.
The home has local Protection of Vulnerable Adults guidelines in place. The
home has made five Safeguarding adults referrals; all have been resolved.
Staff receive Protection of Vulnerable Adults training during their induction, a
more formal training is required to meet National Minimum Standards. The
home ordered a training video during this inspection, which will be used in the
future for Protection of Vulnerable Adults training. Staff spoken to demonstrated good knowledge of referral and recording procedures around adult protection issues.
Environment

The intended outcomes for Standards 19 – 26 are:
19.
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):
People using the service experience good outcomes in this area.
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 who live there. The home is well lit, clean and tidy and
smells fresh.
EVIDENCE:
The care home premises consist of a large detached house located in
considerable grounds. Over the years there has been extensions added to the
building. The garden is well maintained. The home is generally well
decorated. The home has a passenger lift in the main part of the house; the
alarm bell was not working on the lift. The lift was however serviced according
to LOLER Regulations. The registered provider must contact the lift engineer
and the alarm bell must be repaired. People using the service bedrooms that
were inspected were generally large, light and airy. There was evidence of these bedrooms being personalised. People using the service kindly showed me items of furniture, pictures and other personalised items that they had brought with them from their previous home. There is a staff room in the old part of the home. There is a gate protecting people using the service and staff from falling down the stairs. I noted during the inspection that this gate was open and informed the registered manager to ensure that the gate is closed at all times. The home has two flats, which are used by people who are more independent. The care home is clean and pleasant. There are several domestic staff that are employed in the care home. These staff were working during the inspection, and it was evident that significant and appropriate cleaning is carried out in the care home. Laundry facilities are located away from food storage and food preparation areas. The washing and the clothes drying machines are industrial machines. Hand washing facilities are located throughout the care home. Staff were observed to wear protective clothing including disposable gloves and aprons.
Staffing

The intended outcomes for Standards 27 – 30 are:
27.
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):
People using the service experience good outcomes in this area.
This judgement has been made using available evidence including a visit to
this service.
The service has plentiful staff available at all times to support the needs,
activities and aspirations of the people using the service in an individualised
and person centred way. The service is innovative and shows a high level of
awareness of staffing levels needed. Staff members undertake external
qualifications beyond the basic requirements. Managers encourage and enable
this and recognise the benefits of a skilled, trained workforce. The service
ensures that all staff receive relevant training that is focussed on delivering
improved outcomes for people using the service. The service has a good
recruitment procedure that clearly defines the process to be followed.
EVIDENCE:

The home has approximately 110 staff employed; this consists of Registered
Nurses, Carers, cooks, and domestic and maintenance staff. I have viewed
staffing rotas during this inspection, during morning shifts 21 carers and three
Registered Nurses are on duty, during afternoon shifts 13 carers and 2
Registered Nurses are on duty and eight staff including Registered Nurse are
on duty, this is judged as very good staffing. People using the service informed
me that they rarely have to wait for staff support.
The registered manager informed me that 40 out of 60 care staff have or currently working towards achieving their National Vocational Qualification in Care. This is 67% and exceeds National Minimum Standards. I spoke to a care assessor during this inspection who informed me that the home is taking staff training very seriously and support staff to achieve their National Vocational Qualification in Care. I assessed six staffing files during this key inspection; all files showed that the required records and documentation such as Criminal Records Bureau checks, references, passport copy, etc. were on file. The home has a recruitment policy in place, which has been reviewed in September 2007. Staff have to undertake induction training when they commence employment; records of this can be assessed in individual files. Staffing records demonstrate that staff have varied training, ranging from mandatory training to specialist training. The registered manager is providing staff training. She has the necessary qualifications and knowledge to do this. Staff spoke positively about the training they have received since working in the home.
Management and Administration


The intended outcomes for Standards 31 – 38 are:

31.
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. 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):
People using the service experience good outcomes in this area.
This judgement has been made using available evidence including a visit to
this service.
The registered manager has the required qualification and experience, is highly
competent to run the home and meets its stated aims and objectives. The
manager is aware of current developments both nationally and by Commission
for Social Care Inspection and plans the service accordingly.
The home works to a clear health and safety policy, staff are aware of the
policy and are trained to put theory into practice. The registered person has
the skills and ability to deliver good business planning, and effective financial
controls. They provide a quality assurance and monitoring process to ensure
efficient running of the home, which gives value for money and delivers
effective outcomes for the people who use the service.
EVIDENCE:


The registered manager is a trained nurse and is experienced in working with
older persons needing care and support. She reported that she had received
her certificate in regard to completing NVQ level 4-5 in management course.
It was evident from speaking with the manager that she had knowledge and
understanding (and a great interest) in the conditions /diseases associated
with old age. She spoke of having recently completed a dementia care training
course. The manager was observed to interact with people using the service
and visitors in a positive, friendly and respectful manner, and it was evident
that she knew them well. People using the service and staff spoke highly about
the registered manager, her listening skills and support provided.
The home is undertaking residents and stakeholder’s surveys annually. The
home has received 23 responses from relatives (11 excellent, 11 good and 1
poor), as stated in the Annual Quality Assurance Assessment. People using the
service meet every two months, care staff meets four times per year, records
of these meetings have been viewed during this inspection. The home has an
annual quality assurance and development plan in place.
The home does not manage people using the service finances. People using the
service and relatives told me that the home invoices personal expenditure
monthly. Fees and charges are clearly displayed on the homes website and
service users guide.
The registered manager informed me that she has started providing 1 to 1
supervision for staff. I have seen evidence of this in individual files assessed.
The registered manager has allocated supervisees to senior staff to undertake
regular supervisions in the future. I informed the registered manager that all
staff must receive a minimum of six planned supervisions per year.
I have viewed fire records, which have all been in order and of good standard,
a detailed fire risk assessment is in place and fire equipment and alarms have
been checked regularly. The registered provider gave me a folder with Health
and safety checks and certificates; all of these were up to date and have been
renewed when required.

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
3 Standard Met
2 Standard Almost Met
(Minor Shortfalls) 1 Standard Not Met (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
ENVIRONMENT
Standard No
Score
Standard No
Score
HEALTH AND PERSONAL CARE
Standard No
Score
STAFFING
Standard No
DAILY LIFE AND SOCIAL
ACTIVITIES
Standard No
MANAGEMENT AND
ADMINISTRATION
Standard No
COMPLAINTS AND PROTECTION
Standard No
Are there any outstanding requirements from the last
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.
development in assessment
(including risk assessment) of
the use of bedrails and there
needs to evidence of agreement
from the service users (if
practicable) and/or relatives.
This assessment in regard to the
use of bedrails needs to be
carried out by a competent
person, and be reviewed
regularly.
(Previous timescale of
01/03/07 not met)

lift must be repaired to be able to call someone in case of an emergency. room must be closed safely at all times to ensure the safety of people using the service and staff. minimum of six planned supervisions per year to ensure staff as well as people using the service are supported appropriatly.
RECOMMENDATIONS
These recommendations relate to National Minimum Standards and are seen
as good practice for the Registered Provider/s to consider carrying out.
Commission for Social Care Inspection
Harrow Area office
Fourth Floor
Aspect Gate
166 College Road
Harrow
HA1 1BH
National Enquiry Line:
Telephone: 0845 015 0120 or 0191 233 3323
Textphone: 0845 015 2255 or 0191 233 3588
Email: [email protected]
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

Source: http://www.kestrelgrove.co.uk/file-store/nov_insp_report.pdf