CARE HOMES FOR OLDER PEOPLE
Kilkenny Residential Care Home 6 Third Avenue Frinton On Sea Essex CO13 9EG Lead Inspector
Marion Angold Key Unannounced Inspection 27th June 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 Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Kilkenny Residential Care Home Address 6 Third Avenue Frinton On Sea Essex CO13 9EG 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) 01255 672253 01206 855219 Mr Rajalingum Valaydon Mrs Christine Joan Emmamdeen, Mr Mamode Farouk Emmamdeen Mr Rajalingum Valaydon Mrs Teresa Rosaline Jones Care Home 11 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (11), Old age, not falling within any other of places category (11) Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 11 persons) Persons of either sex, aged 65 years or over, who require care by reason of dementia (not to exceed 11 persons) One person, under the age of 65 years, who requires care by reason of dementia, whose name was made known to the Commission in April 2005 The total number of service users accommodated in the home must not exceed 11 persons 5th January 2006 Date of last inspection Brief Description of the Service: The Kilkenny is situated in a residential area on the outskirts of Frinton town centre, close to the sea front and within walking distance of all local amenities. Bedrooms upstairs can be accessed by means of a chairlift. There is a hardstanding area at the front of the home with a seat and space for two or three cars. An enclosed, paved garden is at the rear of the property. The home provides care for 11 older people, aged over 65 years. In 2005 the registration was varied so that the home may admit people with dementia. The current weekly charge for a room is between £350.00 and £375.00 per week. Additional charges are made for chiropody, manicures, hairdressing, toiletries, newspapers and confectionary. Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection, covering the key National Minimum Standards, took into consideration all recent records and contacts relating to the service, including information sent to the Commission by the Providers. It also included a site visit to the home on 27/6/06, lasting 9.5 hours. This involved speaking with residents, provider, manager and staff, as well as a partial tour of premises, observation of care practice and the sampling of records. Where possible, the site visit focussed on the experience of a sample of 3 residents, a process known as case tracking. Since the last inspection, Mrs Teresa Jones had been registered as the second manager of the home. Of the 23 Standards inspected, 13 were met, 8 presented minor shortfalls and, 2, a significant shortfall. What the service does well: What has improved since the last inspection?
In line with a requirement made at the last inspection, all records requested for inspection were available on the premises. Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 6 Residents care plans were being reviewed every month, so that important changes could be identified and addressed. Written procedures for adult protection had been brought in line with locally agreed guidelines and staff had attended related training. A number of improvements had been made to the environment, including the ongoing replacement of windows and upgrading of the first floor bathroom. Signage, helpful to some people with dementia, was being used more discerningly around the home. Obstructions on the stairs to the staff flat (second-floor), noted at the last two inspections, and causing a risk to residents in the event of a fire, had been removed. Residents’ health and safety had been promoted through the review and updating of risk assessments, particularly in relation to the environment and chemical products used by the home. What they could do better:
The home’s Statement of Purpose and Service Users’ Guide, reviewed in January 2006, met regulatory requirements but were not particularly well written or user-friendly. Records of residents’ daily progress demonstrated that some staff lacked understanding of the potential effect of dementia on mood and behaviour. The registered persons had compiled a resource folder on dementia care but need to ensure that staff have adequate knowledge and skills in this area. It was therefore encouraging to hear that further dementia care training had been planned. Although at the time of inspection, 8 hours a week were dedicated to supporting residents with activities, and some excellent person-centred activities were taking place, more could be done to provide mental stimulation and variation in activity for residents who needed help to mobilise. Although there was some choice of menu, residents did not know in advance what would be served. Feedback was given to Mrs Jones about the benefits to residents of displaying, and inviting discussion about the daily menu. Not all relatives and representatives were aware of the home’s complaints procedures. The registered persons should ensure that people have the information they need to raise any issues they might have. To minimise the risk of infection, the registered persons need to ensure that all staff follow accepted procedures for washing their hands. It was of serious concern that at least three people working at the home lacked recruitment records and other documentation required by regulation. There
Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 7 was no evidence of supervision or training for these staff and one person had no records at all. The registered persons responded to an immediate requirement notice from the Commission by addressing these shortfalls. A more robust approach to recruitment, supervision and staff training is needed in the interests of residents’ safety and well being, and to protect them from abuse. It was also noted that entries on the duty roster of staff covering peak times were specified by name only. The registered persons are required to ensure that the duty roster shows the hours actually worked by each member of staff. The home is achieving some good outcomes for residents but the registered persons should develop a more comprehensive system of quality monitoring, to ensure that all aspects of the service are subject to ongoing review and improvement and that regulatory requirements are being met. 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. Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 8 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 Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 9 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 and 3. NMS 6 did not apply to The Kilkenny. The quality of service in this outcome area has been assessed as adequate, based on the following judgements: • • Information given to prospective residents was comprehensive but not always well written. Residents had their needs assessed before being offered a place in the home. EVIDENCE: The home’s Statement of Purpose and Service Users’ Guide, revised in January 2006, met regulatory requirements but were not well written in places. No new residents had been admitted since the last inspection. Evidence from previous inspections, and a sample of residents’ records, showed that residents’ needs were comprehensively assessed and planned for, in discussion with the residents, their representatives and the referring authority. The
Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 10 managers stated that they would not admit anyone to the home without assessing their needs and being sure the home could meet them. Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 11 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 quality of service in this outcome area has been assessed as good, based on the following judgements: • • • • Residents benefited from a person-centred approach to care planning. Residents’ health care needs are met. Residents are protected by the home’s policies and procedures for dealing with medicines. Residents are treated with respect and given privacy. EVIDENCE: Residents benefited from comprehensive care plans, based on individual profiles and an assessment of their individual needs and strengths. These plans were evaluated every month and appropriately amended. Daily records, which helped inform these monthly evaluations, were linked to care plans. Particular comments made by staff in the daily records, such as reference to someone being ‘in a mood’, suggested some lack of understanding of the person’s dementia. This is covered under the section on staff training. Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 12 One person, responding to the Commission’s survey, did not feel that the home were proactive in keeping them informed or consulting them about their relative’s care but indicated that they were given information if they phoned. Residents indicated that the home were attentive to their health care needs. Relatives, representatives and medical professionals expressed similar views. The latter indicated that the home communicated clearly and worked in partnership with them. Detailed records were maintained for a person, whose appetite had declined and staff had instructions to prompt and monitor fluid intake. Mobile residents were taken for walks. One care plan sampled showed clearly the person’s progress in physical and mental health and mobility. Procedures for ordering, storing and administering medication were found to promote safe practice. Medication Administration Records were in order and care plans amended to reflect changes in medication. Mrs Jones, who assumed overall responsibility for ensuring that residents received their medicines, as required, had received the appropriate level of medicines training. Medical professionals, responding to the CSCI survey, affirmed that they were able to see residents in private. Residents said their privacy was respected. Staff also respected their preferred names. The inspector observed nothing on this occasion that infringed the privacy of any resident. Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality of service in this outcome area has been assessed as good, based on the following judgements: • • • • The diversity of residents’ lifestyles and backgrounds was reflected in some of their daily routines and activities. Residents benefited from an open visiting policy. Residents were helped to exercise choice and control over their lives. Residents received a wholesome, appealing and balanced diet in pleasant surroundings. EVIDENCE: Care plans, records and discussions with staff and residents showed that residents’ daily routines were, as far as possible, flexible and self-determined. For example anyone who wished to stay in bed in the morning, or have breakfast in their room, could do so and care plans gave details of people’s usual times of going to bed. One person described how they benefited from being able to determine their own routines. At the time of inspection, eight hours of staff time per week were dedicated to supporting residents with activities. Records showed that residents had participated in a variety of activities, both in and outside the home. The day of inspection coincided with one of the weekly activity sessions and several
Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 14 residents had been accompanied on a walk along the seafront. Residents indicated that they enjoyed the activities. The television was on for most of the morning and this was varied with some music in the afternoon. Staff on duty were attentive to residents and engaged them in conversation at different times during the day, as they had opportunity, or enabled them to assist with small domestic tasks. It was observed that residents, who needed help to mobilise, spent significant periods without much mental stimulation or variation in their activity. The home had not changed its visiting policy and there was evidence from observation and comments that residents and their representatives were completely satisfied with existing arrangements. One person, who had no contact with family or friends, had an advocate to represent their interests. Some residents continued to eat their meals in their armchairs rather than at a dining table. This meant less exercise or variation of position for people with poor mobility and reduced opportunity for the communication that coming together would provide. Although it was evident from observation and discussion that people were being given the option of moving to the dining table, most residents continued to eat at individual tables, as they had always done. Residents were given encouragement to eat and were able to finish their meal at their own pace. Although there was some choice of menu, residents did not know in advance what would be served. Although lunch was served ready plated, tea was presented on a trolley, making it easier for residents with dementia, to make informed choices. Residents were also offered a choice of beverages. Feedback was given to Mrs Jones about the benefits to residents of displaying the daily menu and getting them involved in menu planning. Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality of service in this outcome area has been assessed as adequate, based on the following judgements: • • Residents’ interests would be better served if all their relatives and representatives were aware of the home’s complaints procedures. Poor recruitment procedures had placed residents at risk of abuse. EVIDENCE: The home’s record of complaints had no new entries since August 2005, and residents and relatives said that they had not had cause to complain. The home’s quality assurance policy referred to residents having freedom to complain and unrestricted access to CSCI inspectors; residents also felt that they could say if they were not happy about something and that managers and staff would listen. However, several relatives and representatives, replying to the CSCI survey, indicated that they were unaware of the home’s complaints procedures. This might deter them from raising any concerns. The adult protection policy and procedures had been revised and brought in line with guidelines issues by the Essex Vulnerable Adults Protection Committee. Staff had also attended related training. Observation and comments from residents, and others replying to the CSCI survey, evidenced that residents were well treated by staff. However, failure to carry out for all staff the pre-employment checks, required by regulation, had placed residents at risk of abuse.
Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 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 and 26 The quality of service in this outcome area has been assessed as good, based on the following judgements: • • Residents lived in a safe, well-maintained environment. The home was clean, pleasant and, in the main, hygienic. EVIDENCE: The bathroom on the first floor had been refitted since the last inspection and the new bath was more suited to the needs of people with poor mobility. Bedrooms sampled were comfortable, homely and safe and contained adequate furniture, fixtures and fittings. Signs had been removed from the bedroom doors where the occupants did not need them. Replacement windows had now been fitted throughout the home. Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 17 Access to the paved area at the back of the house was through the kitchen or quiet lounge. Both options required residents to negotiate a step although a portable wooden ramp was available for wheelchair access. Laundry facilities were adequate for the needs of the residents. Suitable facilities were available for staff to wash their hands but one person, as observed, put the health of residents at risk by not following recommended procedures for washing their hands. The registered persons must ensure that all staff have had adequate training in this area. Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 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 and 30 The quality of service in this outcome area has been assessed as poor, based on the following judgements: • • Staff were available in sufficient numbers to meet residents’ basic needs. Residents were not always protected by the home’s recruitment and training practices. EVIDENCE: Medical professionals, responding to the CSCI survey, indicated that there was always a senior member of staff to confer with. Residents said that staff were nearly always available to help them when needed; relatives also indicated that, in their view, there were sufficient numbers of staff on duty. Records showed that there were always two staff in attendance, supplemented by an additional person at peak times, an activity coordinator for 8 hours per week, and ancillary staff from Monday to Friday. Advice was given in respect of the duty rosters, as these did not specify the actual hours put in by the member of staff covering the busy times. At least three people working at the home lacked recruitment records and other documentation required by regulation. There was no evidence of supervision or induction and other training for these staff. There were no records at all for one person working at the home. These are serious omissions, putting the health and safety of residents at risk. It was also
Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 19 established that one person had been in charge of the night shift, who was under 21 years old. Training was covered by the home’s annual plan and staff continued to attend periodic training in both health and safety and practice topics. Although most care staff had received some training in dementia awareness, records of residents’ daily progress demonstrated that some lacked understanding of the potential effect of dementia on mood and behaviour. It was, therefore, encouraging to note that further training in dementia care was planned. The registered persons were also advised, through meetings and individual staff supervision, to raise staff awareness of the learning resources available in the home, such as the dementia care periodical and information folder. Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 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, 33, 35, 36 and 38 The quality of service in this outcome area has been assessed as adequate, based on the following judgements: • • • • The home was generally well run, although breaches of regulation in respect of recruitment, supervision and training gave cause for concern. The home was achieving some good outcomes for residents but not all aspects of the service were being routinely monitored to ensure the highest possible standards of care. Residents’ financial interests were safeguarded. The health, safety and welfare of residents and staff were promoted and protected. EVIDENCE: Mrs Jones’ application to be registered as the second manager of the Kilkenny was approved by the Commission in June 2006. Mr Valaydon and Mrs Jones run The Kilkenny on family lines and, by sharing the management
Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 21 responsibilities, also cover shifts, thereby keeping in touch with the changing needs of residents and the contribution of individual staff. However, it was brought to their attention that, knowing or being related to the people they recruit does not obviate the need for all the procedures and checks, required by regulation and they were required to take immediate action to address the shortfalls identified. The registered persons had developed a quality assurance policy and conducted a survey or residents’ views in March 2006. However, the business plan, presented for inspection, was not clearly linked to quality reviews and mainly covered the premises and staff development. They need to ensure that all aspects of the care they provide to residents are subject to monitoring and improvement and that regulatory requirements are being met. The home continued to hold small amounts of personal money on behalf of residents. Records receipts and balances were found to be accurate as sampled. Records showed that residents’ outgoings mostly covered the additional charges made by the home, as listed at the beginning of this report. Not all staff had been receiving one-on-one supervision to support and guide them in their roles. Records of supervision that had taken place indicated a lack of discussion about practice issues and missed opportunities for learning. It was suggested, for example, that the managers use the home’s resource folder on dementia care in supervision and staff meetings as a means of promoting good practice in this area. Obstructions on the stairs to the staff flat (second-floor), noted at the last two inspections, and causing a risk to residents in the event of a fire, had been removed. The first aid box had also been replenished, as required by the Environmental Health inspectorate. Residents’ health and safety had been promoted through the review and updating of risk assessments, both in relation to the environment and the chemical products used by the home. Arrangements had been made for staff to undertake a distance-learning course on various aspects of health and safety. Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 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 OP16 Regulation 22 Requirement The registered persons must supply a copy of the complaints procedure to any person acting on behalf of a resident. The registered persons must ensure that they carry out all the recruitment procedures required by regulation. They must also obtain for each person, prior to their appointment, full and satisfactory information and documentation, as per Regulation 19, Schedule 2 and Regulation 17, Schedule 4. Timescale for action 31/08/06 2. OP18 OP29OP31 13, 17 Sh 4 19 Sh 2 10/07/06 3. OP27 OP37 17 (2) 7 4. OP30 18 (1) 5. OP33 24 The registered persons must 07/08/06 ensure that the duty roster of persons working in the care home specifies the hours actually worked by each member of staff. The registered persons must 10/07/06 ensure that all persons working in the home receive appropriate training. THIS REQUIREMENT HAS EXCEEDED AGREED TIMESCALES FOR ACTION SINCE THE INSPECTION ON 5/01/06 The registered persons must 30/09/06 ensure that all aspects of the
DS0000017862.V301594.R01.S.doc Version 5.2 Page 24 Kilkenny Residential Care Home 6. OP36 18 (2) care they provide are subject to regular monitoring and review. They must supply to the Commission, and to residents/their representatives, a copy of the report in respect of any quality review conducted by them. The registered persons must 10/07/06 ensure that staff are appropriately supervised. THIS REQUIREMENT HAS EXCEEDED AGREED TIMESCALES FOR ACTION SINCE THE INSPECTION ON 23/08/05. 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 OP1 Good Practice Recommendations The registered persons should continue to revise the Statement of Purpose and Service Users Guide to remove typing and grammatical errors and present the information in a manner, which is easier to follow. The registered persons should make arrangements to increase the mental stimulation and vary activity for people with poor mobility. The registered persons should give residents more information and involvement in relation to menus. The registered persons should ensure that persons left in charge of the home are over 21 years of age. 2. OP12 3. 4. OP15 OP27 Kilkenny Residential Care Home DS0000017862.V301594.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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