Inspection on 17/04/07 for Kilburn Care Centre

This inspection was carried out on 17th April 2007.

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

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

Other inspections for this house

Kilburn Care Centre 22/06/06

Kilburn Care Centre 05/10/05

Kilburn Care Centre 09/12/04

Kilburn Care Centre 12/07/04

Kilburn Care Centre 22/03/04

Kilburn Care Centre 23/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Kilburn Care Centre Dale Park Avenue Kilburn Belper Derbyshire DE56 0NR Lead Inspector Rose Veale Key Unannounced Inspection 17th April 2007 09:45 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 Kilburn Care Centre DS0000058025.V334075.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. Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kilburn Care Centre Address Dale Park Avenue Kilburn Belper Derbyshire DE56 0NR 01332 880644 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) kilburnnursing@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited Mr Chris Cooper Care Home with nursing 49 Category(ies) of Old age, not falling within any other category registration, with number (49) of places Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. To admit one (named) service user under the age of 65 years in the category of PD. One DE(E) place for the service user named in the notice of proposal letter dated 24/11/04. One DE(E) place for the service user (EM) as named in the notice of proposal letter dated 05/05/05. The registered person will be responsible for informing the Commission for Social Care Inspection when the named individuals no longer reside at Kilburn Care Centre. 22nd June 2006 Date of last inspection Brief Description of the Service: Kilburn Care Centre is in a village location, close to local shops, churches, pubs and other facilities. The home was two homes, which have been joined to create one registered home. One was a converted building, the other purpose built. Currently the converted building has residents requiring personal care and the purpose built section has residents requiring nursing care. The home can accommodate up to 49 older people. Most of the bedrooms are single and have en-suite facilities. There is a garden area to the rear of the home and car parking to the front. Fees charged at the home range from £308.50 to £487.50 per week for residents requiring personal care, and from £430.15 to £600.00 per week for residents requiring nursing care. This information was provided by the manager on 18/04/07. Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and took place over 8 hours. The inspection visit focused on assessing compliance to requirements made at the previous inspection and on assessing all the key standards. There were 46 residents accommodated in the home on the day of the inspection, including 31 residents assessed as needing nursing care. 5 residents, 3 visitors and 6 staff were spoken with during the visit. The manager was available and helpful throughout the inspection visit. Some residents were unable to contribute directly to the inspection process because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. Records were examined, including the care records of 4 residents, 4 staff records, maintenance and health and safety records. A tour of the building was carried out. A questionnaire had been completed and was returned during the inspection visit. 9 of the surveys sent out to residents had been completed and returned. Telephone surveys were carried out of 4 of the residents’ representatives. Information from the questionnaire and surveys has been included in the body of this report. What the service does well: What has improved since the last inspection? The 2 requirements made at the last inspection had been met, resulting in improvements to the environment of the home. The activities coordinator had been appointed since the last inspection and had introduced a range of activities. Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 6 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. Kilburn Care Centre DS0000058025.V334075.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 Kilburn Care Centre DS0000058025.V334075.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was a good assessment system so that residents were confident their needs could be met at the home. EVIDENCE: The care records of 4 residents were examined and all included a range of assessment information. Assessment had been carried out prior to the admission of the resident by social services staff and by staff from the home. There were also assessments carried out on or soon after admission. 1 resident and 1 visitor spoken with confirmed that the residents had been assessed prior to admission, and 1 resident had visited the home before admission. Responses from the surveys indicated that residents felt they generally received the care and support they needed. Standard 6 did not apply to this service. Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 9 Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 10 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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although basic care needs appeared to be met, residents’ holistic needs, including their social and emotional needs, were not always met. EVIDENCE: Each of the 4 care records seen included a care plan produced from the assessment information. The care plans covered the assessed needs of the residents and included details of their personal preferences regarding care and daily routines. 2 of the care plans included reference to maintaining the privacy and dignity of residents. All the care plans seen had been reviewed monthly up to date. There was nothing recorded to indicate that the resident and / or their representative had been involved in devising the care plan. The 4 care records seen included assessments of the risk of developing pressure sores, the risk of falls, nutritional needs, continence needs, and the level of dependency of the resident. All the assessments seen had been reviewed monthly to date. Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 11 There were mixed responses from residents and their relatives about whether the care needs of residents were met at the home. The responses to the surveys were mostly positive about residents having the care and support they needed. There were several positive comments received from residents and relatives spoken with and those responding to the surveys, including “they look after you well”, “they treat me well here”, and “Mum has improved since moving here”. There was a comment that staff had been good at encouraging a resident to become more mobile. There were comments that residents were not assisted to take sufficient drinks during the day. There were comments received about when specific individual needs had not been met, such as lack of referral to other healthcare professionals, and lack of suitable equipment. There were several comments that there was a lack of stimulation for residents. It was observed that residents’ basic care needs appeared to be met. Staff spoken with were knowledgeable about the care needs and preferences of individual residents. Staff training records showed that staff had received training appropriate to the needs of residents. Records were seen of the input of other healthcare professionals, such as the GP, District Nurse, chiropodist and optician. There was evidence that residents were referred through the GP to services such as community physiotherapy and hospital specialists. The GP visited the home every Thursday for a ‘mini surgery’, and other times as required. Residents and visitors spoken with were generally satisfied that staff promoted the privacy and dignity of residents. It was commented, and also observed, that residents sometimes were not assisted to ensure their hands and faces were clean after meals. It was also commented that residents were sometimes still sitting at the dining table over an hour after the meal had finished. As noted above and in the next section of this report, there were comments that there was a lack of stimulation for residents. There were 2 storage areas for medication in the home. The medication for the residents needing nursing care was stored in a room on the first floor and was administered by the registered nurse on duty. The medication for residents not requiring nursing care was stored in a ground floor room and also in a trolley in the dining area and was administered by senior care assistants or the registered nurse on duty. The senior care assistants had received appropriate training about the safe handling and administration of medication. The door to the first floor storage room had been fitted with a suitable ventilation grill, as required at the last inspection. There were daily records kept of the temperature of the storage room that showed the temperature was consistently above 25 degrees centigrade, which could adversely affect some Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 12 medication. There were daily records of the temperature of the fridge used to store medication, but not of the minimum and maximum temperatures. It was important to ensure that the fridge temperature had remained within the correct temperature limits for the safe storage of medication such as insulin. The Medication Administration Records, (MARs), were checked for 4 residents. All were correctly completed. Each of the MARs included a photograph of the resident and brief details of any allergies or special needs regarding medication. Medication received into the home was recorded on the MARs. Medication was disposed of by a waste disposal company and was not recorded on the MARs or elsewhere. Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although a range of activities was offered, the provision was not sufficient to meet the social needs of all residents. EVIDENCE: There was an activities coordinator working for 30 hours per week who had been in post since September 2006. There were records of activities offered to residents and of their response, positive and negative, to activities. The care records included details of the resident’s family and social history and preferences regarding activities. There was a range of activities provided for residents, including trips out, visiting entertainers, fund raising events, quizzes and games. It was clear that activities were offered to meet the expressed preferences and past interests of residents. For example, there were residents who had previously enjoyed watching football who regularly went with staff to local matches. Residents were assisted and encouraged to make use of local facilities, such as going out for a pub lunch, using local shops, or playing bowls in the park. Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 14 Despite the range of activities offered, there were comments received that there were not enough activities or stimulation for residents. It was commented that the lounge in the ‘residential’ part of the home was “depressing” as there was no view, and also that there was a lack of stimulation for residents using this lounge – “they’re all asleep”. One relative said that the resident regularly complained of being “bored”. It was observed that residents with dementia did not appear to be involved in meaningful activities. The dissatisfaction with activities could be due to the hours allowed for the activities coordinator being insufficient for the number of residents living in the home. The activities coordinator said they had help from staff on duty when possible, and also staff working voluntarily when taking residents out. There was a small amount of administrative help allowed for the activities coordinator, but this was said to be not available every week. Residents who wished to were taken to a service at a local church, usually once a month. A local vicar visited the home every month to see residents. Visitors spoken with said they were always made welcome and were able to visit at any reasonable time. The main lounge in the part of the home was large with 2 televisions and chairs arranged in four groups. It was commented on and observed that the lounge could be quite noisy and offer little privacy for visitors. Although there were ‘quiet’ lounges available, visitors spoken with said they were reluctant to move the resident from the main lounge as this could be tiring for the resident and time consuming. The ‘quiet’ lounges seen did not appear to be used often by residents or visitors and appeared to be used for storage of supplies and equipment. Residents spoken with and those responding to the surveys were satisfied with the meals provided at the home. Residents and visitors spoken with said that there was always a choice offered. The menu was displayed in the dining areas. There were comments that residents were not offered drinks frequently enough throughout the day. Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 15 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure was not sufficiently robust to ensure that residents complaints were listened to and acted upon. Residents were protected by the systems in place and by staff awareness regarding safeguarding vulnerable adults. EVIDENCE: There were records of complaints with details of the action taken and the outcome. There were no complaints recorded after June 2006. In discussion with the manager, it was said that this was because no ‘serious’ complaints had been received. Some of the relatives spoken with said they had raised concerns with the manager or staff since June 2006. Those who had raised concerns said the manager had listened and most said that appropriate action had been taken. However, there were comments that the problems sometimes reoccurred, or that sometimes action did not appear to have been taken. Most residents and visitors spoken with said they were aware of who to complain to. There were 2 comments received that they did not know about the complaints procedure. Staff training records showed that most staff had received training in safeguarding vulnerable adults. Staff spoken with were aware of what constituted abuse and of the correct procedures to follow if abuse was Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 16 suspected. There was evidence that the home had dealt with allegations of abuse in an appropriate and timely manner. Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A lack of prompt response to repairs needed was affecting residents’ choices and causing frustration for staff. EVIDENCE: A tour of the home was carried out including some bedrooms, the bathrooms, and the communal areas. The home appeared generally adequately maintained. There were 2 bathrooms on the ground floor out of use because the bath hoists were awaiting repair. It was found that the bathrooms had been out of use for approximately 6 weeks prior to the day of the inspection visit. The manager had sent the quote for the repairs needed to the providers at the beginning of March 2007 and had then followed this up approximately 4 weeks later as no response had been received. On the day of the inspection visit, a response was received that the quote had been sent to the head office for approval. Residents were able to use other bathrooms / shower rooms in Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 18 the home, although the lack of 2 bathrooms limited their choice and caused frustration for staff. The home was reasonably decorated throughout, although there were some areas that appeared ‘tired’ and ready for redecoration, such as the small kitchen and one of the bathrooms. The home was generally adequately equipped to meet the needs of residents. Some new profiling beds with integral bed rails had been provided since the last inspection. Some of the wheelchairs in the home appeared in a poor and worn condition, although records seen showed that wheelchairs were regularly checked and maintained. It was commented that the footplates did not always fit properly. The manager said that residents had been referred for assessment for wheelchairs for their individual needs but the process was slow. A requirement was made at the last inspection to ensure that the rear patio area, drive and steps were safe for use by residents. Work had been carried out to comply with this requirement. On the day of the inspection visit the home was clean and free from offensive odours throughout. Residents and visitors spoken with, and those responding to the surveys said the home was usually clean and fresh. Staff spoken with had received training in infection control and staff records showed that most staff had received training. Staff were observed to use disposable gloves and aprons when assisting with personal care. Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were good recruitment practices, a commitment to training, and adequate staffing levels so that residents were protected and were supported by competent staff. EVIDENCE: The staffing rotas showed that there were 2 qualified nurses on duty for the morning shift and 1 nurse on duty for the afternoon and night shifts. There were 6 or 7 care assistants on duty for the morning shift, 5 or 6 for the afternoon shift, and 4 for the night shift. The nurses and care staff were supported by kitchen, laundry and domestic staff. According to the assessed dependencies of residents in the home, the staffing levels met the guidance of the Residential Forum tool for care hours in homes for older people. Staff were allocated to either the ‘nursing’ part of the home, or the ‘residential’ part, (those residents requiring help with personal care only). Residents and visitors spoken with, and those responding to the surveys said that staffing levels appeared adequate and that staff were usually available when needed. Staff spoken with were generally satisfied with staffing levels. The ‘residential’ part usually had 3 care staff for the morning shift and sometimes 2 for the afternoon shift. There were comments that 2 staff in the afternoon was not always sufficient because there were times when both staff Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 20 would be assisting one resident with personal care, leaving no-one around for the other residents. The records of 4 members of staff seen included all the required information, such as Criminal Records Bureau disclosures and 2 written references. There were records of staff induction and training. Staff spoken with confirmed that they had completed an induction process that included a period of shadowing an experienced member of staff. The induction programme was based on the Skills for Care standards. The records seen did not include evidence of how staff had achieved competence in all of the stated areas. Staff training records showed that most staff had received training in fire safety, manual handling, food hygiene, safeguarding vulnerable adults, health and safety, and infection control. Most staff had also received training in dementia awareness, pressure area care, and nutritional needs. Of 29 care staff, 10 had already achieved a National Vocational Qualification, (NVQ), at level 2 or 3, and 9 were working towards achieving NVQ. Staff spoken with said that training was encouraged at the home. Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 21 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was a lack of robust management so that residents’ and staff views and concerns were not always taken into account. EVIDENCE: The manager was suitably qualified and experienced to run the home. There were positive comments received about the manager, including that he was ‘approachable’ and ‘hands on’ when needed. There were also comments that the style of management tended to be reactive rather than proactive and that there was a lack of firmness of approach at times. The quality assurance system included sending out surveys to residents / their representatives, monthly audits by the manager, and monthly visits by the Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 22 operations manager. The manager said that action was taken to address issues raised on the surveys returned by residents / their representatives, although there was no written evidence of this. There was no report produced of the analysis of quality assurance measures with action taken to address issues raised. As noted in the Complaints and Protection section of this report, there was a lack of a robust approach to complaints. There was a system in place for residents’ personal money held by the home. Access to residents’ personal money was restricted to the manager and administrator. Records were kept with details of each transaction and receipts. The records were audited every year by the provider organisation. The balances checked on the day of the inspection visit were correct. Health and safety records were sampled, including the fire log book, accident book, and maintenance records. All the records seen were up to date. As noted in the Environment section of this report, there had been delays in ensuring essential maintenance had been carried out to 2 of the bathrooms. Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X 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 2 X 2 X 3 X X 2 Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement There must be a record of all medication leaving the home to ensure the safety of residents and to ensure that medication is correctly disposed of. Medication must be stored at the correct temperature to ensure it is fit to be given to residents. A record must be kept of all complaints made and of the action taken so that residents/ their representatives are confident their complaints are taken seriously. The 2 bathrooms identified must be restored to working order so that residents have a choice of safe bathing facilities. Timescale for action 31/05/07 2. 3. OP9 OP16 13(2) 17(2) 31/05/07 31/05/07 4. OP19 23(2)(c) 31/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 25 1. 2. OP7 OP9 3. 4. 5. OP12 OP30 OP33 Residents / their representatives should be encouraged to be actively involved in devising care plans to ensure that residents’ needs are fully met. The minimum and maximum daily temperatures of the medication fridge should be recorded to ensure medication is stored at the correct temperature and is fit to be given to residents. Further provision should be made to ensure there are activities offered to meet the needs of all residents. There should be records of the induction programme for new staff that show how the staff member has achieved competence. The quality assurance system should include a report to residents/their representatives to show the action taken to improve the service based on their views and comments. Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kilburn Care Centre DS0000058025.V334075.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!