Inspection on 15/03/06 for Kilcreggan Residential Care Home

This inspection was carried out on 15th March 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kilcreggan Residential Care Home 26/06/09

Kilcreggan Residential Care Home 22/06/07

Kilcreggan Residential Care Home 26/04/06

Kilcreggan Residential Care Home 14/01/06

Kilcreggan Residential Care Home 15/03/05

Kilcreggan Residential Care Home 10/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Kilcreggan Residential Care Home 35 Ashburton Road Claughton Village Birkenhead Wirral CH43 8TN Lead Inspector Beate Roth Unannounced Inspection 15th March 2006 10:30 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.V286696.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.V286696.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.V286696.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th January 2006 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 has 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.V286696.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 5 hours. During the inspection time was spent 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: It is of concern that the requirements made at the last inspection relating to recruitment records, fire safety training and fire drills are outstanding. There are a number of improvements that need to be made in order for this service to comply with the Care Homes Regulations 2001 and meet the National Minimum Standards for Care Homes for Older People. The service user care plans must contain clear information as to the action staff are to take to meet the needs of the service users. A record must be made to indicate that medication has been administered, in accordance with the home’s medication procedure. 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. Kilcreggan Residential Care Home DS0000045141.V286696.R01.S.doc Version 5.1 Page 6 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 fully support the well being of service users. Improvements need to be made to the frequency of the fire safety instruction provided to staff and the records of this 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.V286696.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.V286696.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. No new service users have come to live at the home since the last inspection. At the last inspection, there was evidence of appropriate assessments being undertaken, a social work assessment was available for a service user who was admitted from hospital and a social work assessment was available for a service user who had moved from another home. Service users are encouraged to make 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.V286696.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, 9 and 10 The health care needs of service users are met. Service users are treated with respect. Improvements are needed to care planning and to the home’s procedures for dealing with medicines in order to ensure service users 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, these plans identify the current needs of service users but some care plans do not provide sufficient information for staff around the action to be taken to meet these needs. A discussion took place with the deputy manager around the action that needs to be taken to address this. 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. Kilcreggan Residential Care Home DS0000045141.V286696.R01.S.doc Version 5.1 Page 10 A record of accidents were examined and were satisfactorily maintained. CSCI has been notified of any significant events at the home. The service users and a relative spoken with commented very positively on the standard of care provided by staff. Comments from service users included “ the girls are very good if you need something,” “the girls are wonderful.” 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. There were three incidents of the medication not being signed for. This was brought to the attention of the manager and the deputy manager, who said that they would address this issue without delay. A copy of the Royal Pharmaceutical Guidelines around the administration of medicines in care homes is available at the home. It is recommended that the homes medication procedure be reviewed to ensure that it adheres to this. Since the last inspection, the risk assessments in place for service users who administer all or some of their own medication have been reviewed. These assessments continue to contain 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. Staff were observed to treat service users with respect. Staff were observed to speak to service users in a respectful manner and knocked at bedroom doors before entering. The service users and a relative interviewed said that the staff are “polite,” “friendly,” “helpful” and “kind.” Staff receive guidance on promoting the dignity of service users. Kilcreggan Residential Care Home DS0000045141.V286696.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): 12 and 15 The routines of daily living are flexible and activities are available that reflect needs and preferences. Service users receive varied, well-balanced meals, which they enjoy. EVIDENCE: Discussion with service users and staff indicated that the home’s routines are flexible and met service users’ expectations, as much as possible. The home encourages service users to make decisions about their day-to-day lives at the home, such as when they will get up and go to bed and what they will do each day. At the time of the inspection, service users were receiving visitors, watching television or reading. The home encourages service users to carry on with the interests and activities they enjoyed whilst living in their own homes rather than providing a range of group activities. The deputy manager reported that this is in accordance with the wishes of service users. The deputy manager reported that in the past a range of weekly activities were organised but that service users chose not to participate. At present a couple of activities are organised each week following a discussion with the service users. Questionnaires about the service provided have recently been sent by the home to all service users. Kilcreggan Residential Care Home DS0000045141.V286696.R01.S.doc Version 5.1 Page 12 The 9 questionnaires returned indicated that all but one service user were happy with the activities provided. The deputy manager reported that she will address this. The 9 questionnaires completed by service users indicated that they are in general happy with the food provided. 2 comments were made about having a greater choice of meals. The deputy manager has been speaking to individual service users about this. The records of food indicated that varied meals are provided that offer a balanced diet. The deputy manager reported that a choice is available at each mealtime but is not recorded on the menu. This information needs to be available for service users. A dietician is approached for advice where necessary. Service users spoken with said that they enjoy their meals and that they are offered an alternative if they do not want what is on the menu. Kilcreggan Residential Care Home DS0000045141.V286696.R01.S.doc Version 5.1 Page 13 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 and 18 The home has a satisfactory complaints system which service users know how to access. The adult protection procedures at the home safeguard service users. EVIDENCE: The home has a complaints procedure, a copy of which is included in the Service User Guide. The address and telephone number of the Commission for Social Care Inspection is 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. The service users spoken with 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. The home has a copy of Wirral Social Services adult protection procedures. The adult protection procedure is discussed with all staff during their induction. The home has a booklet, which briefly details the adult protection procedure and allows the manager to elicit whether the staff have understood the content. The staff interviewed were aware of the content of the adult protection procedure and that any adult protection concerns must be reported to the manager immediately. Kilcreggan Residential Care Home DS0000045141.V286696.R01.S.doc Version 5.1 Page 14 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 clean and in general, satisfactorily maintained. EVIDENCE: There is evidence of ongoing decorative and maintenance work at the home to maintain standards. At this inspection the kitchen has been refurbished and consultation has taken place with the environmental health department who have advised that some minor improvements are needed. The owner was in the process of attending to this at the time of the inspection. The communal areas are in general satisfactorily maintained. 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 owner reported that there are plans to redecorate this area within the next couple of months. The progress of this will be looked at the next inspection. A sample of bedrooms were seen. These were suitably maintained. Service users said that the staff keep their bedrooms clean. Service users have personalised their bedrooms. Kilcreggan Residential Care Home DS0000045141.V286696.R01.S.doc Version 5.1 Page 15 Thermostatic mixing valves with lockable temperature controls are fitted to baths and sinks. At the time of the inspection the water was of a safe temperature. A number of radiators at the home have been fitted with protective covers. At the last inspection, the radiators on the top floor of the home that are covered with metal covers were very hot in two bedrooms seen. 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. These radiators were a safe temperature at the time of the inspection. The deputy manager reported that regular checks of the temperature of radiators, which have metal covers, is occurring. The registered person must ensure that service users are at all times protected from any risks presented by the temperature of radiators. At the last inspection, a requirement was made that a risk assessment take place of the stairs to the basement that are accessible to service users. A bedroom used to be provided to a service user in the basement of the home. This is no longer in use. At this inspection a sturdy, low-level gate has been placed across the top of the stairs. The owner reported that the gate is making it difficult for staff to access the basement when they are carrying laundry. The owner reported that a further risk assessment will be undertaken and consultation will take place with the environmental health department and the planning department for advice. Until this risk assessment is completed the owner reported that the gate will remain in place. The CSCI would remind the registered persons that the safety of service users in the home environment is of paramount importance. The home was clean and free from malodours during this unannounced inspection. Kilcreggan Residential Care Home DS0000045141.V286696.R01.S.doc Version 5.1 Page 16 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 There are sufficient numbers of staff to meet the needs of service users. The recruitment practices at the home do not fully safeguard service users. Service users benefit from a number of staff having completed an NVQ 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 provides for two care staff and a manager to be on duty from 8am until 9pm. 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. At this inspection the times worked by the manager and deputy manager are clearly documented on the rota. Management and care staff do the cooking. A cleaner is employed and the Registered Person does maintenance work. A number of staff have been employed at the home for several years, this promotes continuity of care. Two members of staff interviewed reported that they consider there are sufficient staff available to meet the needs of service users. 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 all the certificates be held on staff files. Kilcreggan Residential Care Home DS0000045141.V286696.R01.S.doc Version 5.1 Page 17 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 continues to be employed without the registered person obtaining a satisfactory CRB or POVA First check. A CRB from this member of staff’s former employer had been obtained. A further member of staff had been employed who has until very recently lived in another country. A criminal records check had only taken place with the appropriate authorities in the UK. This is not acceptable and does not safeguard the wellbeing of service users. At previous inspections a requirement has been made that the staff training programme be formalised. This requirement has not been fully met. 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. Work is needed to ensure that the induction training 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.V286696.R01.S.doc Version 5.1 Page 18 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, 35, 36 and 38 The arrangements for quality assurance and supervision of staff do not fully support the well being of service users. Improvements need to be made to the frequency of the fire safety instruction provided to staff and the records of this 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. 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.V286696.R01.S.doc Version 5.1 Page 19 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. Since the last inspection, questionnaires have been given to all service users. If the results from these questionnaires could be formed into a coordinated response, with an action plan for future development, this would enable the home to meet the relevant requirements. Additionally a questionnaire for GP’s, district nurses and other visiting professionals would complete the quality assurance process. In general, the financial affairs of service users are managed by the service users themselves, or by their family. The home receives the personal allowance for a service user from a relative. This service users money is passed on to the service user on receipt. The service user and a manager sign this record. Care needs to be taken to ensure that the balance is entered and deducted each time money is received and given to the service user. Service users are able to bring personal possessions to the home. A requirement has been made at the previous inspections that a staff supervision system be put in place whereby all staff working at the home are appropriately supervised and a record is 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. Records are kept in the medication room, the manager’s small office and in the owners living accommodation. Some records could not be easily found at this inspection. Although the staff reported that they are able to access the information they need, improvements should be made to the storage of records so as to ensure they are fully accessible. At the last inspection, a requirement was made that a record be made of fire drills and fire safety training provided to staff. This has not been addressed. Evidence was not therefore available that staff have received regular instruction on the fire safety procedures. One member of staff said that they had last received fire safety training 2 years ago. Kilcreggan Residential Care Home DS0000045141.V286696.R01.S.doc Version 5.1 Page 20 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 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 1 2 1 Kilcreggan Residential Care Home DS0000045141.V286696.R01.S.doc Version 5.1 Page 21 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 OP7 Regulation 15 Requirement The registered persons must ensure that service user care plans contain clear information as to how staff are to meet service users needs. The registered persons must ensure that a detailed risk assessment is documented for any service users who choose to administer their own medication (previous timescale of 14/01/06 not met). The registered persons must ensure that a record is made to indicate that medication has been administered in accordance with the home’s medication procedure. The registered persons must ensure that staff are not employed before a satisfactory CRB and POVA check or in exceptional circumstances, POVA First check have been received (previous timescale of 14/01/06 not met). The Registered Persons must ensure that the staff training programme is formalised. DS0000045141.V286696.R01.S.doc Timescale for action 15/03/06 2 OP9 13 15/03/06 3 OP9 13 15/03/06 4 OP29 19 15/03/06 5 OP30 18, 19 14/04/06 Kilcreggan Residential Care Home Version 5.1 Page 22 6 OP33 24 7 OP35 17 8 OP36 18 9 OP38 23 10 OP38 23 (previous timescale of 14/04/06 has not expired). The Registered Persons must ensure that a review and development plan is put in place (previous timescale of 14/04/06 has not expired). The registered person must ensure that the amount of money received on behalf of a service user and given to the service user is recorded. The Registered Persons must ensure that a staff supervision system is put in place (previous timescale of 14/04/06 has not expired). The Registered Persons must ensure that a record is made of fire safety training provided to staff that a record of fire drills is maintained (previous timescale of 14/01/06 not met). The Registered Persons must ensure that all staff are provided with training in fire prevention and the fire procedure, at suitable intervals. 14/04/06 15/03/06 14/04/06 15/03/06 15/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations It is recommended that the homes medication procedure be reviewed to ensure that it adheres to the Royal Pharmaceutical Guidelines around the administration of medicines in care homes. The menu record should record the choice of food available at each mealtime. It is recommended that a copy of the NVQ and all other training certificates be held on staff files. DS0000045141.V286696.R01.S.doc Version 5.1 Page 23 2 3 OP15 OP28 Kilcreggan Residential Care Home 4 5 OP31 OP37 The manager is to complete an NVQ 4 in care and management or equivalent. Improvements should be made to the storage of records so as to ensure they are fully accessible. Kilcreggan Residential Care Home DS0000045141.V286696.R01.S.doc Version 5.1 Page 24 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.V286696.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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