Inspection on 26/04/06 for Kilcreggan Residential Care Home

This inspection was carried out on 26th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 15/03/06

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 Mrs Julie Garrity Unannounced Inspection 26th April 2006 10:00 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.V292420.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.V292420.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.V292420.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Kilcreggan is registered to provide personal care only 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 15 bedrooms. At present all the rooms are used as single rooms, all but one room is large enough to accommodate a married couple if they wish. The home is no smoking. 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. The garden is well maintained and is easily accessed by the residents. There is a lift, that serves all floors but some areas of the home are only accessible by steps. There are appropriate sloping ramps that enable less mobile individuals to access the home with. Security access is in place at the front door. All visitors must ring the doorbell to gain access to the building. Car parking is available at the front of the home. Kilcreggan is close to bus routes to Birkenhead and community facilities in Claughton Village. This is a family business, the former owner is the Registered Manager, her son is the Registered Individual and his wife is the deputy manager. The family live in a bungalow, which is attached to the home. Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over a period of one day. The inspector arrived at the home at 11:15 and left at 19.17. The inspector spoke with 6 residents, 2 visitors, 2 relatives, 3 staff the deputy manager and the responsible individual. The inspectors completed the inspection by a site visit to Kilcraggen, a review of records available in Kilcraggen and CSCI offices, discussions with residents, relatives, visitors, staff and management. Questionnaires were sent to the home for residents but now where returned prior to completion of this report. Copies of records were submitted to CSCI for review in this inspection. The inspector followed an inspection plan written before the start of the inspection to ensure that all areas identified in need of review where covered. All of the Key standards were covered in this inspection, these are detailed in the report. Feedback was given to the manager and her deputy during and at the end of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 6 The home has a strong staff team and this has lead to a reliance on verbal communication. The reliance on verbal communication means that written records are either not in available, incomplete or not updated. These have included care plans, risk assessment, medications, policies and procedures, staff training and staff individual records. A lack of appropriate records and training has resulted in inconstancy in the quality of care provided and a lack of clear guidance to staff. This runs the risk of residents receiving the wrong care or being placed at risk. Safety issues also need addressing these included a need to consult with the Fire Authority for advice and guidance and Environmental Health. Management roles is unclear and individual responsibilities are confused. A clear definition of responsibility needs to be made. 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.V292420.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.V292420.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): 1, 2, 3, 4 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to Kilcraggen. The assessment process helps the manager and deputy manager to decide if they can meet the needs of the residents. Residents are only admitted to the home when they feel confident that the home can meet their needs. EVIDENCE: The manager and deputy manager undertake and assessment for all potential residents. The manager has past experience as a nurse and the deputy has 20 years experience in the home. Both use these skills to assist in assessments. A recently admitted resident’s family detailed that all aspects of admission to the home had been discussed. He detailed that the assessment was “informative, useful and help me choose for mum to live here”. A contact and service users guide had not been given to the resident or her relatives at this time. The manager explained that the service users guide was being updated. The home offers a trail period to all newly admitted residents. The new service user did not have a Social Worker involved in her care. Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 9 None of the assessments are recorded and this will make it more difficult for staff to fully understand resident’s needs. Information in the home such as service users guide and Statement of purpose are not printed in large print or on tape for the residents living in the home with visual impairment. All information is discussed with residents prior to admission. Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to Kilcraggen. Resident’s dignity and privacy is well maintained. However poor records and a reliance on verbal communication place residents at risk of receiving inappropriate care and do not safeguard them. EVIDENCE: Four residents care plans were read. The majority of the staff have worked in the home for several years many over 10 years. Discussions with staff detailed that they had a reasonable understanding of the residents needs but they approached the care needs of the residents in an inconsistent manner. One resident said “the staff are excellent, but some do things differently to others and its not always the way I want”. All the residents spoken with were very positive about the care provided comments included “very well cared for”, “looked after by brilliant, kind staff” and “ lovely staff, who look after me well”. The care plans contained no clear assessments. Care needs where not always identified or recorded. Examples included two residents had a pressure ulcer that was being treated by the district nurses but was not detailed in the care plans, residents with continence needs were not detailed. Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 11 Staff did not access the care plans to gain instructions. Daily records for the residents did not detail what care was delivered that day. Care plans had no involvement from residents or their relatives. All care plans were reviewed on a monthly basis with an overview of how the care needs had been meet that monthly and on a yearly basis. Residents and relatives spoken with had not seen a care plan two were unaware of what a care plan was. Risk assessments for identified needs such as falls, moving and handling and pressure ulcers were not available. Residents spoken with said that they were able to visit GP’s, Opticians and dentists as needed. Two residents stated that they had recently seen the GP. The glasses of all the residents who needed them were clean and in a good state of repair. There were no records in the home of professional intervention such as District nurses, GP’s chiropodist etc. Staff simply told each other what the professional said to do. Three residents are receiving care from a consultant geriatrician, there was no records relating to these appointments or their purpose. Medications were reviewed. Most medications were contained in a locked cupboard, which could not be accessed by residents. The home supports residents to keep and manage their own medications. Staff have received training in using the current system in. Records for medications were not accurately maintained this included medications received in the home, handwritten records and signatures for medications given. Three medications for residents were checked there where inconstancies in the amount of medications that should still have been available to give. Residents who were self-medicating had risk assessments in place but these do not contain enough information to determine the safety of the residents. The medication policy was weak and did not give the staff all the information that they needed to give medications consistently to a good standard. Two staff spoken with had read the medicines policy but could not recall what it contained. Staff competency had not been determined by the manager and regular audits on medications had not been undertaken by the manager. There were no instructions for PRN medications for all but one resident. There was no care planning arrangements for creams such as where they should be applied, when and how. Staff tell each other this information. Residents gave examples of how staff treat them with dignity and respect this included “they always knock on the door”, “staff are polite at all times” and “bunch of great girls”. Staff were observed during the day to speak to residents in an appropriate manner. Respect and an understanding of individual needs was displayed. Staff were clearly aware of visual and hearing impairments and adjusted their approach accordingly. Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to Kilcraggen. The routines of daily living are flexible and activities are available that reflects needs and preferences of the residents. Residents receive a variety of meals, which the majority of residents enjoy. EVIDENCE: Residents spoken with make a range of choices for themselves, “I’m not bored. I like spending time in my room and don’t really want to leave it”, another said, “I’m very happy here, my family comes and takes me out regularly, I visit old friends”. There are no records in the home that detail resident’s choices or preferences. Staff spoken with and the deputy manager were confident that they knew what the residents like. This may be appropriate for residents and staff who have spent a lot of time in the home, however new staff will rely on verbal information and it will take a long time to find out the choices of new residents or determine when residents choices change. Residents spoken with were clear that although there are not formally organised activities they were making choices that suited them one resident said, Although there is no set menu staff discuss with residents previous to each meal what is available. Residents spoken with generally liked the food one Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 13 resident said “it’s lovely I eat everything” another resident said “its very nice”. Two residents spoken with found the food was, “same all the time”, however they thought it was “tasty”. Staff spoken with were clear that residents could have a snack or a drink at anytime not all the residents spoken with were aware of this. Two residents were clear that if they don’t like the food on offer an alternative would be made. Staff explained that as the home has thirteen residents it is very easy to make an alternative. Records of food given did detail an alternative for one resident. On the day of the site visit. Residents are weighed on admission however staff do not regularly monitor residents weight. There are set routines in the home that include when residents have a bath, all residents spoken with detailed when they have a bath. However all the residents also detailed that they were offered a choice over a shower or a bath. Two residents also explained that is requested a different time date could be arranged or as and when the resident wanted a bath. Relatives spoken with detailed that they are encouraged to visit, one relative attend the home every night after work and is invited for Sunday lunch with his relative. The resident and relative said, “ it’s great to have a sort of family time and the food is lovely. It’s a really nice occasion”. Another relative attend regular and takes their relative out for the day. All relatives spoken with said that they were “welcomed” in the home”. They find it a very “friendly, inviting place, with lovely staff”. There are currently no residents or relatives meetings that would elicit the resident’s point of view. The manager intends to commence residents meetings in the future to formally explore resident’s preferences. Informal opportunities are undertaken on a daily basis, staff were observed to check with residents over a variety of choices such as the temperature of the room and if they liked the door open. Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to Kilcraggen. Residents are confident that their concerns will be addressed. However a lack of training and thorough policies for the Protection of Vulnerable Adults places residents at risk. EVIDENCE: One resident detailed that he had raised concerns about a resident that regularly “wandered” into his bedroom. This was raised with the Deputy manager who addressed his concerns and discussed ways to resolve the situation. The Deputy manager detailed that this was formally recorded as a compliant. Residents spoken with said, “ I would have no problem saying if something wasn’t right”, another said, “I have said things that I didn’t like and it was fixed”. None of the residents spoken with were aware of a compliants procedure but all where sure that would be “comfortable” to discuss any issues and that it would be “fixed”. A policy on making a complaint is available on display in the home and in the service users guide. Discussions with staff detailed that they understood how to raise concerns about the care that residents may receive with the deputy manager. They were also able to briefly explain what they saw as a potential abuse of residents. Staff were unaware that Social Services are responsible for potential Protection of Vulnerable Adults complaints. The deputy manager mainly takes day-to-day responsibility for the management of the home and was also unaware that the decision as to whether an issue is a potential Protection of Vulnerable Adults is Social Services. Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 15 The home has received a copy of “NO Secrets”, which is Wirral Social Services policy on Protection of Vulnerable Adults, the deputy manager detailed that this had been discussed with the staff. All the policies in this area are brief and do not cover all aspects. There is a policy on how the home would deal with a Protection of Vulnerable Adults complaints raised and although recently reviewed it is brief and does not detail all the information that staff and residents would need. Staff have not received training either at induction or part of their own development in this area. Some staff discussed this aspect when they undertook National Vocational Qualifications, which for some staff was a number of years ago. Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 16 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, 20, 21,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to Kilcraggen. The home management has invested considerable funds in maintaining a clean, welcoming environment appreciated by the residents. Further advice and guidance from Environmental health would assist in maintaining good hygiene standards. EVIDENCE: The home management team have spent a considerable amount of money on refurbishing the kitchen. There are two lounges and a dinning room. All but one of the bedrooms have ensuite facilities. All the bathrooms viewed were clean and tidy. There is an assisted bath for residents who prefer a bath and shower facilities that are suitable to residents needs. The kitchen was clean and tidy. Staff used tabards when cooking and cleaning. Fridge temperatures are regularly recorded. Not all the food items were stated appropriately. Some of the staff dealing with the cooking do not have food and hygiene certificates. Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 17 Many of the residents are independent enough to undertake some of their own cleaning activities. However this is not documented in any area and is difficult to determine what support the staff needs. 8 rooms were viewed, all where clean tidy and personalised by the residents. Residents can lock their bedrooms should they choose to do so and all had a lockable space to store valuables. There are 15 bedrooms although the home is registered for 19 residents. At present all the rooms are used as singles, all but one is a size suitable to share. The home keeps the opportunity to admit and care for married couples should they be asked to do so. Equipment in the home is maintained, certificates were available for gas, electricity and PAT testing. The home cares for three residents who use pads, two residents who have dressings renewed and another resident with a stoma bag. There are no clinical waste arrangements and consultation with environmental health had not been undertaken. All bedrooms have an adjustable thermostat to allow the residents to change the temperature of their bedrooms. All taps in the home have water restrictors in place to prevent the temperatures being too high and scalding residents. Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 18 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): 27,28,29,30 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to Kilcraggen. An established team of staff assists in maintaining a continuity of care delivered to residents. However a lack of records relating to recruitment, induction and training process are not sufficient to fully safeguard the residents. EVIDENCE: The home has thirteen residents in residence at the moment. A recruitment policy and equal opportunities policy and procedure are available. The majority of staff have worked in the home for a considerable amount of time. Of the members of staff spoken with one had worked in the home for over 20 years, another over 17 years and another nearly 8 years. The manager has owned the home since the day it opened and the deputy has worked in Kilcraggen for 20 years. Staff files were reviewed, one file had only one written reference although a verbal reference had been received. A newly recruited member of staff did not have their Criminal Records Bureau applied for before commencing, verbal references had been undertaken, all written references were not available. Supervision arrangements were unclear, there was no written arrangements for supervision for staff working awaiting a Criminal Records Bureau check. One resident said, “staff are great, they know what they are doing, really kind and make sure I get what I need”. Training arrangements were unclear. Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 19 Of the staff files viewed all had moving and handling certificates that were out of date. Certificates for medication training were available but determination of staff competency in this area was not available. There are three residents with dementia needs and mental health needs staff have not received training in this area. The deputy manager and RI say that fire training has been done but no records of this were available. Induction records are available for all new staff members, but were brief and did not cover National Training Organisation standards. The majority of staff learn their new job with the support of staff who have worked in the home for several years. Resident’s needs were determined by the manager and usage of the Residential Forum Guidelines detailed that 310 hrs care per week was needed. Staff supplied are 252 hours per week. However both the deputy manager and manager are frequently available as they live on site as does the responsible individual. Residents and staff detailed that there was “enough” staff available. Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 20 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, 32, 33, 34, 35, 36, 37,38 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to Kilcraggen. There is a need for management to take a more proactive approach in maintaining the systems in the home such as training, records and health and safety. EVIDENCE: Kilcraggen is a family run business the home has been owned by the registered manager since 1978. She has been the manager since 1982. The manager’s son is the Responsible Individual and part owner of the home. The manager’s daughter in law is the deputy manager and part owner of the home. The management of the home is undertaken by the deputy manager who is available in the home nearly 7 days a week, she undertakes all off duty arrangements, assessments of residents, employment checks, ordering of medicines, care planning and records within the home. One resident said of the deputy “she’s a lovely manager, knows what she’s doing and is very kind”. Neither the manager nor the deputy have formal management qualifications. Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 21 They both have experience in the home and the manager was a registered nurse. As a family run home there is a reliance on verbal communication, a stable staff team supports this. Policies and procedures a number of are now out of date, not representative of the care provided or changes in legislation. The staff spoken with are aware that policies and procedures were available and did not read them and none were signed that staff had read and understood them. The home has undertaken a formal quality assurance that detailed 1 star from a potential 5. Residents, relatives and staff meetings are not undertaken, the manager detailed that this was something she would like to progress. The management time do not do audits of their own in the home such as medicines, care plans, environment, supervision and training. The home is not appointee for any residents. The home does not deal with resident’s personal finances unless specifically asked. They receive £10 per week for one resident, which is given directly to him and signed for. Other residents are either dealing with their own funds or this is managed by family members. The deputy manager has created a new form for undertaking staff supervisions on a formal basis but this has not been put into place as yet. Informal supervision is on going on a daily basis as the deputy works along side all of the staff. Certificates were available for all key areas such as, gas electricity and PAT testing. All where in date. Fire alarms and emergency lighting where regularly recorded. Risk assessments for a number of areas such as moving and handling were not undertaken. Clinical Waste arrangements were not available. Three bedroom doors and the day room door were noted to wedged open. The home has a number of risk assessments in place for the environment many of these have not been updated for over 2 years. Footrests for wheelchairs were missing from one wheelchair. The arrangements for maintaining the wheelchairs were unclear. The accident book was viewed and a number of accidents recorded where not reported to CSCI. The Deputy manager detailed that they had not been aware that all accidents should be reported this way. Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 2 3 2 2 2 Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 23 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 (1) (2) Requirement The registered persons must ensure that service user care plans contain clear information as to how staff are to meet service users needs. (This is outstanding from the previous report) Risk assessments must be utilised for residents identified at risk, such as moving and handling, falls, nutritional needs, development of pressure ulcers etc The registered person must undertake monthly audits on medication to make sure that staff are competent and administrating medications in accordance with the Royal Pharmaceutical Guidelines. The registered persons must ensure that staff who are employed before a Criminal Records Bureau is completed must have a Criminal Records Bureau applied for, a Protection of Vulnerable Adults first received. This is applicable in DS0000045141.V292420.R01.S.doc Timescale for action 26/06/06 2. OP9 13 (4) 26/06/06 3. OP9 13 (2) 26/06/06 4. OP29 19 (1) 26/04/06 Kilcreggan Residential Care Home Version 5.1 Page 24 exceptional circumstances only CSCI must be informed and the individual must be supervised at all times until receipt of a Criminal Records Bureau. 5. OP30 18 (1) (a) (c) (i) The Registered Persons must ensure that the staff training programme is formalised. (This is outstanding from two previous report) The Registered Persons must ensure that a staff supervision system is put in place (this is outstanding from two previous report) The manager must contact Environmental health for advice and guidance regarding Clinical Waste and The Fire Authority for advice and guidance regarding fire safety. This must include recording of staff training, doors wedged open, fire risk assessments and fire drills. 26/05/06 6. OP36 18 (2) 26/05/06 7. OP38 16 (2) 26/05/06 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 2 3 4 Refer to Standard OP1 OP9 OP9 OP9 Good Practice Recommendations The manager should make sure that the information in the home is available in formats suitable to all the residents needs The manager should make sure that all assessments of prospective residents is recorded to assist in forming a care plan that clearly meets residents needs. All handwritten medications instructions should contain label directions signed by the person writing the recorded checked and signed by another member of staff. All PRN medications should have clear instructions as to when the medication is suitable to administrated. DS0000045141.V292420.R01.S.doc Version 5.1 Page 25 Kilcreggan Residential Care Home 5 6 OP9 OP9 7 8 OP9 OP9 9 10 11 OP9 OP9 OP27 Medications should remain in a locked cupboard at all times. Risk assessments for self-administration of medications should have full details such as security, resident’s ability and understanding of medications. They should be regularly reviewed and signed and dated by the person completing the record. The medication policy should be update to provide all the information that staff need to order, monitor, store, record, give and return medications safely. Monitor opened medications to make sure that they remain in date. Most medications expire 3 months after opening. Guidance from the pharmacist should be sought as to expiry dates for particular medicines. Staff should always take MAR records with them when giving out medications and sign for each resident individually immediately on giving the medication. Care should be taken with liquid medications to make sure that they are accurately given. Staff training should be explored per individual staff member that includes Protection of Vulnerable Adults training, Moving and handling training, Dementia, Challenging behaviour, Fire Safety and food hygiene The home should regularly monitor residents dependency needs in order to determine that staffing levels are appropriate to the needs of the residents. 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. 12 13 14 OP27 OP31 OP37 Kilcreggan Residential Care Home DS0000045141.V292420.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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. 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