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Inspection on 14/01/06 for Kilcreggan Residential Care Home

Also see our care home review for Kilcreggan Residential Care Home for more information

This inspection was carried out on 14th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

An appropriate assessment of whether the home is suitable for new service users takes place. Service users are provided with opportunities to visit the home to decide if the home will meet their needs. Service users have access to health and social care professionals in accordance with their needs. The staff support the personal care needs of service users. The needs of service users are met by the arrangements for visitors to the home and by the arrangements for promoting their independence. There is a satisfactory complaints system in operation. Service users benefit from a number of staff having completed NVQ training in care of the elderly.

What has improved since the last inspection?

There have been some improvements to the records that are required to be held at the home in accordance with requirements made at the last inspection. There have been improvements to the appearance of the home as ongoing decorative work has taken place to maintain standards.

What the care home could do better:

A number of improvements need to be made in order to fully support and promote the wellbeing of the service users living at the home. Improvements need to be made to the risk assessments undertaken before service users administer their own medication in order to ensure they are fully safeguarded. The rota must clearly indicate the hours worked by the manager and deputy manager in order to demonstrate that there are sufficient numbers of staff available at all times. The recruitment practices at the home do not fully safeguard service users. The registered persons must ensure that the recruitment information that is required by law is available for all new care staff employed at the home. Service users would benefit from staff receiving induction and foundation training that meets the National Training Organisation(NTO) workforce training targets. Improvements need to be made to the arrangements for quality assurance and supervision of staff as at present these do not support the well being of service users. Improvements need to be made to the fire safety recording systems in order to demonstrate that service users are fully safeguarded.

CARE HOMES FOR OLDER PEOPLE Kilcreggan Residential Care Home 35 Ashburton Road Claughton Village Birkenhead Wirral CH43 8TN Lead Inspector Beate Roth Unannounced Inspection 14th January 2006 10:15 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 Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 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. Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kilcreggan Residential Care Home Address 35 Ashburton Road Claughton Village Birkenhead Wirral CH43 8TN 0151 652 0845 0151 653 8183 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) Kilcreggan Residential Care Home Limited Mrs Jean Koltuniak Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th March 2005 Brief Description of the Service: Kilcreggan is registered to provide personal care for 19 older people. The home is a detached, three storey house situated near to Claughton Village in Birkenhead. The home has been extended over the years and provides accommodation in 16 bedrooms. 13 single and 3 double. At the time of this inspection the rooms were used for single occupancy only and the Registered Persons confirmed that they would only use a room for sharing should a married or similar couple express a positive desire to share a room. The bedrooms are spacious and all but one have en suite facilities. Kilcreggan has a dining room and two lounges on the ground floor. The dining room and one lounge look out on to a courtyard style garden. There is a shaft lift, which serves all floors but some areas of the home are only accessible by steps. Car parking is available at the front of the home. Kilcreggan is close to bus routes to Birkenhead and community facilities in Claughton Village. Kilcreggan is a family business, the former owner is the Registered Manager, her son is the Registered Person and his wife is the deputy manager. The family live in a bungalow, which is attached to the home. Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 7 and a half hours. During the inspection time was spent in the office examining records and policies and procedures and talking to the manager, deputy manager and the responsible person. A tour of the home was undertaken. Staff were observed delivering care to service users. Service users and staff were spoken with. What the service does well: What has improved since the last inspection? What they could do better: A number of improvements need to be made in order to fully support and promote the wellbeing of the service users living at the home. Improvements need to be made to the risk assessments undertaken before service users administer their own medication in order to ensure they are fully safeguarded. The rota must clearly indicate the hours worked by the manager and deputy manager in order to demonstrate that there are sufficient numbers of staff available at all times. The recruitment practices at the home do not fully safeguard service users. The registered persons must ensure that the recruitment information that is required by law is available for all new care staff employed at the home. Service users would benefit from staff receiving induction and foundation training that meets the National Training Organisation Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 6 (NTO) workforce training targets. Improvements need to be made to the arrangements for quality assurance and supervision of staff as at present these do not support the well being of service users. Improvements need to be made to the fire safety recording systems in order to demonstrate that service users are fully safeguarded. 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. Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 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 Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 An appropriate assessment of whether the home is suitable for new service users takes place. Service users are provided with opportunities to visit the home to decide if the home will meet their needs. EVIDENCE: The manager or deputy manager carries out an assessment of service users before they are admitted to the home. A visit is made to service users where they are living and information is gathered from the service user, relatives and relevant professionals. There was a social work assessment available for a service user who was admitted from hospital and a social work assessment available for a service user who had moved from another home. Service users are encouraged to make extended visits, and where possible overnight stays to the home, before making a final decision as to whether to move in. Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9 The health, personal and social care needs of service users are in general supported by the care planning processes in place at the home. Improvements need to be made to the risk assessments undertaken before service users administer their own medication in order to ensure they are fully safeguarded. EVIDENCE: A sample of service user records were seen and showed that they each have a service user plan and risk assessments. The service user plans are not very detailed, however observation and discussion with the staff and deputy manager indicated that many of the service users are self-caring and their level of dependency is low. The manager and deputy manager review the care plans each month but no formal annual reviews are carried out. The records at the home and a discussion with the deputy manager indicated that referrals are made to health professionals in accordance with the needs of service users. A record is made of visits by health professionals and the outcome is documented. A record of accidents were examined and were satisfactorily maintained. CSCI has been notified of any significant events at the home. Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 10 The service users spoken with commented very positively on the standard of care they receive from the staff. Comments included “ the girls are very good if you need something,” “the girls are wonderful,” “ the staff are attentive, I love it here.” The home uses a NOMAD monitored dosage system. Certificates of staff training indicated that staff have received training in this system. Medication is securely kept in a locked cupboard. Medication Administration Record sheets for three service users and the corresponding medication were seen and found to be in order. The home administers some homely remedies. There was evidence on a service users file that advice had been obtained from a GP before administering a homely remedy. The circumstances in which homely remedies can be administered needs to be indicated in the medication procedure. This procedure was not seen during the inspection and the deputy manager and manager, were not aware if this information is included. At the last inspection a requirement was made that where service users wish to administer all or some of their own medication they must be given all the support needed to do so, but a full, recorded risk assessment must be carried out. At this inspection risk assessments were available but contained insufficient information. The risk assessments need to indicate whether there is a lockable area in which the service user will be able to store the medication safely, whether the service user can read and understand the instructions on the medication and whether the service user is able to administer the medication, for example, open the bottle and measure the dose. The guidelines around when diazepam should be administered on an as and when required basis, was not indicated in the records seen. This information is to be available so that there is clear guidance available for staff. Following he inspection the deputy manager reported that advice had been obtained from the service user’s GP regarding this. Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 14 The needs of service users are met by the arrangements for visitors to the home and by the arrangements for promoting their independence. EVIDENCE: Service users reported that visitors are encouraged and that they are able to see visitors in private as they wish. Service users also said that they are able to choose whom they see and do not see. The visitors record book showed that there had been several visitors to the home on the day of the inspection. Service users are encouraged to manage their own financial affairs. It was evident from service users bedrooms that many of them had bought personal possessions into the home with them. Although no service users currently have an advocate, the deputy manager described circumstances in which they had worked with a service user’s advocate in the past. Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has a satisfactory complaints system which service users know how to access. EVIDENCE: The home has a complaints procedure, a copy of which is included in the Service User Guide. Since the last inspection the address and telephone number of the Commission for Social Care Inspection has been included. The Service User Guide also contains details about advocacy services. There have been no complaints to the home and no complaints about the home have been made to CSCI since the last inspection. 5 service users were spoken with at this inspection, they all said that they would be able to raise any issues they have about the service provided at the home with a member of staff or with the deputy manager or the manager. Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 The home is in general suitably maintained. A risk assessment of some areas of the home is needed in order to safeguard the well being of service users. EVIDENCE: Kilcreggan is located near to bus routes and overlooks a large open area of allotments at the front. Shops and community facilities in Claughton Village are nearby. There is a shaft lift, which, serves all floors but some areas of the home are only accessible by steps. Service users mobility is taken into account when assessments for admissions are being made. There is evidence of ongoing decorative and maintenance work at the home to maintain standards. At this inspection the small lounge at the front of the home had been redecorated. 3 bedrooms had been redecorated. There was some wear and tear to the decoration of the hallways on the first and second floor. The carpets to the hallways on the first and second floor are discoloured in areas. The deputy manager reported this was due to sunlight. The Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 14 registered person reported that there are plans to redecorate this area within 3 months. The progress of this will be looked at the next inspection. At the time of the inspection work had recently begun to refurbish the kitchen. Food preparation and cooking is taking place in the kitchen when refurbishment work is not taking place and the kitchen in the owners’ premises is also available for use. The kitchen is to be completed within one month. In the meantime the registered persons must ensure that food hygiene standards are maintained. Service users spoken with indicated that the works to the kitchen were not disrupting mealtimes and that they receive regular hot drinks and hot food. A sample of bedrooms were seen. These were suitably maintained. Service users said that the staff keep their rooms clean. At the last inspection it was reported that the water on the first floor was too hot. This has been attended to by adjusting the thermostatic mixing valve that controls the water temperature. At the time of the inspection the water was sampled at different points in the home and was of a safe temperature. A number of radiators at the home have been fitted with protective covers. The radiators on the top floor of the home are covered with metal covers. At the time of the inspection these radiators were very hot in two bedrooms seen and could pose a possible risk to service users. The deputy manager was advised to carry out a risk assessment and take appropriate action to address any risks identified. Following the inspection the deputy manager reported that the temperature of the radiators had been adjusted to provide a safe temperature. The registered person must ensure that service users are at all times protected from any risks presented by the temperature of radiators. A bedroom used to be provided to a service user in the basement of the home. This is no longer in use. The stairs to the basement are accessible to service users. The registered person needs to undertake a risk assessment of this and to take any action needed to address the risks identified. The home was clean and free from malodours during this unannounced inspection. Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The rota does not demonstrate that the staffing arrangements at the home fully support service users. The recruitment practices at the home do not fully safeguard service users. Service users benefit from a number of staff having completed a formal training qualification in care of the elderly but they would benefit further from staff receiving induction and foundation training that meets the National Training Organisation (NTO) workforce training targets. EVIDENCE: There were 12 service users living at the home at the time of the inspection. The rota generally provides for two care staff and a manager to be on duty throughout the day. The rota shows that there are 3 times during the week when there is one member of staff available from 6pm to 9pm. Given the layout of the building over 3 floors, this is not sufficient. The deputy manager reported that either the manager or deputy manager are available as the second member of staff. This information was not on the rota. The times worked by the manager and deputy manager to ensure two staff are available at all times must be clearly documented on the rota. The deputy manager reported that a new member of staff is in the process of being recruited to ensure there are 2 care staff available at all times. The service users spoken with reported no staffing problems. A member of staff said 2 staff are available. At night there is a waking member of staff from 9pm to 8am. The manager or deputy are available on sleep-in duty in their attached bungalow. Management and care staff do the cooking. A cleaner is employed and the Registered Person does maintenance work. Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 16 6 out of 12 care staff hold a National Vocational Qualification in the Care of Older People. The training certificates that were available were seen. It is recommended that a copy of the certificates be held on staff files. A number of staff have been employed at the home for several years, this promotes continuity of care. At the last inspection a requirement was made that before any new staff work in the home the registered persons must ensure that staff have a satisfactory POVA and CRB check. At this inspection a member of staff has been employed without first obtaining a CRB or POVA First check. A CRB from this member of staff’s former employer had been obtained. The records of recruitment did not contain evidence that 2 references had been obtained. The deputy manager reported that the references were obtained but the whereabouts of this information could not be located. This is not acceptable and does not safeguard the well-being of service users. At the last inspection a requirement was made that the staff training programme be formalised. This requirement has not been fully met. Since the last inspection a record of the information and training given to staff during their induction is recorded. This covers all policies and procedures, care practices and the operation of the home. The deputy manager and a member of care staff have attended a TOPPS training day during which the TOPPS induction standards were covered. It was discussed with the deputy manager that this information could be used to expand the induction currently provided at the home to ensure all staff are provided with induction training that meets the National Minimum Standards for Care Homes for Older People. Staff are provided with further training following the induction. This is generally around health and safety issues and in diseases and conditions of old age. Again, this needs to be formalised to ensure that staff are provided with training that equips them to meet the assessed needs of the service users accommodated. Records of all training provided need to be readily accessible on staff files. Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 The arrangements for quality assurance and supervision of staff do not support the well being of service users. Improvements need to be made to the fire safety recording systems in order to demonstrate that service users are fully safeguarded. EVIDENCE: The Registered Manager has managed the home since 1982. During the inspection, the deputy manager provided information around the needs of the service users and the operation of the home and it appeared that the deputy manager is undertaking the majority of the managerial tasks at the home. The deputy manager and manager said that the managerial responsibility for the running of the home is shared between the manager and deputy manager, with the manager having overall responsibility. The deputy manager has an NVQ3. In order to fully meet the National Minimum Standards the manager will need to complete an NVQ 4 in care and management. Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 18 There are systems in place for reviewing and improving the quality of care provided at the home. The views of service users and their relatives are obtained and the views of staff are obtained. There continues to be no formal quality assurance system in place that would confirm the success of the home in achieving its stated objectives. The registered person is in the process of re-issuing a questionnaire to service users and their relatives and this would enable the home to meet the relevant requirements if the results could be formed into a coordinated response, with an action plan for future development. Additionally a questionnaire for GP’s, district nurses and other visiting professionals would complete the quality assurance process. A requirement was made at the last inspection that a staff supervision system be put in place whereby all staff working at the home are appropriately supervised and a record maintained of each supervision event. At this inspection, informal supervision is continuing. No records are maintained and the process would not support any actions taken with members of staff to support references or disciplinary action. Appraisals of staff are not currently undertaken. A sample of safety check records were seen. A valid electrical wiring certificate was available. A copy of the test certificate for gas safety was sent to CSCI and indicated that the gas is to be next tested in April 2006, a copy of this certificate could not be found at the home. Weekly tests of the fire alarm and emergency lighting were recorded. There was a record of the hoist and lift services. A record had not been made of fire drills and fire safety training provided to staff. This is to be addressed. Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 19 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X X X X 2 3 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X X 1 X 1 Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 Requirement The registered persons must ensure that a detailed risk assessment is documented for any service users who choose to administer their own medication. The registered persons must ensure that there are guidelines around the administration of diazepam that is to be taken as and when needed, so that there is clear guidance available for staff. The registered persons must ensure that the refurbishment of the kitchen is completed within one month. In the meantime food hygiene standards must be maintained. The registered persons must undertake a risk assessment of the stairs to the basement that are accessible to service users and take any action needed to address the risks identified. The registered persons must ensure that service users are at all times protected from any risks presented by the temperature of radiators. DS0000045141.V277935.R01.S.doc Timescale for action 14/01/06 2. OP9 13 14/01/06 3. OP19 23 14/02/06 4. OP19 23 21/01/06 5. OP25 13 14/01/06 Kilcreggan Residential Care Home Version 5.1 Page 21 6. OP27 17 7. OP29 19 8. OP30 18, 19 9. OP33 24 10. OP36 18 11. OP38 23 12. OP38 23 The registered persons must carry out a risk assessment of the radiators on the top floor of the home that were very hot at the time of the inspection and take appropriate action to address any risks identified. The registered persons must ensure that the times worked by the manager and deputy manager are clearly documented on the rota. The registered persons must ensure that staff are not employed until the recruitment information detailed in Schedule 2 of the Care Homes Regulations 2001 has been obtained. Staff must not be employed before a satisfactory CRB and POVA check or in exceptional circumstances, POVA First check have been received. The Registered Persons must ensure that the staff training programme is formalised. (previous timescale of August 2004 not met). The Registered Persons must ensure that a review and development plan must be put in place (previous timescale of August 2004 not met). The Registered Persons must ensure that a staff supervision system is put in place (previous timescale of August 2004 not met). The Registered Persons must ensure that a record is made of fire safety training provided to staff (previous timescale of May 2005 not met). The Registered Persons must ensure that a record of fire drills is maintained. 14/01/06 14/01/06 14/04/06 14/04/06 14/04/06 14/01/06 14/01/06 Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP28 OP31 Good Practice Recommendations It is recommended that a copy of the NVQ and all other training certificates be held on staff files. The manager is to complete an NVQ 4 in care and management or equivalent. Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 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 Kilcreggan Residential Care Home DS0000045141.V277935.R01.S.doc Version 5.1 Page 24 - 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. 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