Inspection on 11/10/05 for Kirk House Nursing Home

This inspection was carried out on 11th October 2005.

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

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

Other inspections for this house

Kirk House Nursing Home 08/10/07

Kirk House Nursing Home 24/10/06

Kirk House Nursing Home 15/04/05

Kirk House Nursing Home 12/10/04

Kirk House Nursing Home 20/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Kirk House Nursing Home Balance Street Uttoxeter Staffordshire ST14 8JE Lead Inspector Mr David Cowser Announced Inspection 11th October 2005 09:30 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 Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 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. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kirk House Nursing Home Address Balance Street Uttoxeter Staffordshire ST14 8JE 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) 01889 562628 01889 564976 Uttoxeter & District Old People`s Housing Society Limited Mrs Cicely Jane Fountain Care Home 26 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (2), Physical of places disability (10), Physical disability over 65 years of age (26), Terminally ill (4) Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD(E) Minimum aged 60 yrs Date of last inspection 15th April 2005 Brief Description of the Service: Kirk House is a 26-bed Care home providing personal care and nursing care to elderly persons over the age of 60 years with physical disabilities, terminal illness (4 beds), or dementia (2 beds). The home is owned and operated by the Uttoxeter & District Old People`s Housing Society Limited, which is a voluntary organisation. The establishment is an extended three-storey detatched property situated close to the town centre of Uttoxeter, and within easy access to all local amenities and public transport. A homely environment has been created throughout. Hotel services and facilities including laundry and catering are very good, with adequate staffing levels. Activities, hobbies and entertainment all take place and transport is provided when required. Families and friends are encouraged to take part in activities and be involved with the home. A hairdressing salon is provided on the ground floor of the home. Care is delivered by registered nurses and care assistants, led by the Care Manager who is a first level nurse. Staff training is given a high priority, and there has always been a low turnover of staff working in the home. Health service professionals such as district nurse, community psychiatric nurse, and physiotherapist are accessed when required, and local GP’s and a pharmacist service the home. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine announced visit was made on the 11 October 2005 at 09.30hrs. The inspection was undertaken using the National Minimum Standards for Older People as a reference. The total time spent for the inspection, including pre and fieldwork, amounted to 8hrs. The registered care manager (RGN) was in charge of the home accompanied by two more registered nurses and five care assistants. Ancillary staff on duty included; cook and catering assistant, two domestic staff, laundry worker, maintenance/ gardener, and a business support worker. These staffing levels were adequate to meet the needs of current 25 residents in the home. The total of 25 elderly residents included; 19 receiving nursing care for needs associated with physical disablement, 1 with a dementia related condition, and 4 people receiving personal care for needs associate with old age. The inspection included the following elements; a tour of the building, inspection of records relating to provision of care, discussions with eight residents and four relatives, discussions with the staff members on duty, observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing, quality assurance and health & safety. Since the last inspection on 12 October 2004; there had been no changes to the management of the home, no complaints had been received and no additional visits had been necessitated. It was evident that aspects of care had been addressed well, with residents able to choose the home following an assessment and invitation to visit the home. Service user plans had been well written, based on the community care plans completed by social workers. Health, personal and social care needs had been met and well documented. Privacy, dignity and choice aspects for residents were being upheld. Activities and entertainment had taken place but it was recommended that a designated member of staff be employed to coordinate and record these events. No complaints, incidents or reports of abuse of any kind had been received since the last inspection and policies and procedures seen covered these issues. One resident had attended an A&E with a fracture, and no resident had a pressure area. There had been 10 deaths during the past 12 months, which had included patients admitted with a terminal illness. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 6 The home was fit for purpose, well maintained, and provided a safe environment for the residents and staff. A homely atmosphere had been created, and the premised were very clean, warm and tidy. Adequate areas for residents were provided including; communal space, dining/activity space, bathing/toilet facilities, and bedrooms. Services and facilities including catering and laundry were adequately provided. Health and safety aspects had been given a high priority and no shortfalls were noted. Staffing levels and skill mix had been adequate to meet the assessed needs of the existing residents. Recruitment and retention of staff aspects were good. Staff training had been given a high priority, with induction training being followed by NVQ training. Staff had received supervision, though a recommendation is made to further develop the associated documentation. The home appeared to be managed well by a qualified and competent care manager. General management aspects were good with quality assurance taking place. Records had been correctly filed and stored. The home is a registered charity and assurances were given regarding the positive financial viability of the home, and that suitable accounting/business procedures are adopted. No requirements or recommendations, against the regulations or the minimum standards, had been made in the last inspection report. No requirements were made during this inspection. Two recommendations made are identified at the end of this report. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 7 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 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 Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 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): Standards 1,2,3,4,5 The statement of purpose and service user guide was available and also all residents had a contract. All had been given the opportunity to visit the home prior to admission. Individual health, personal and social care needs had been established and documented. All of the above had ensured that the home had the ability to meet the needs of residents within the registered category. EVIDENCE: The documentation seen, and a discussion with residents/representatives, evidenced that residents had been assessed prior to admission and they had been enabled to make a choice about the home. All involved had the opportunity to visit the home prior to choosing to stay. Two residents spoken to had visited the home, and had a meal prior to deciding to stay, and this was seen documented within the care plans. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 10 A full assessment of each residents needs had taken place and this was seen documented. The community care plans provided by the social worker, as part of the individual needs assessment process, were seen within the service user plans. Residents asked confirmed that they had been fully involved and were in agreement with the assessments. The records seen and a discussion with the staff evidenced that nursing and care staff, individually and collectively, had the necessary experience and skills to meet the assessed needs of the current service users. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 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): Standards 7,8,9,10,11 The assessed health and personal care needs of patients and residents had been well documented and were being met, with good standards of care being delivered. There was a safe system for the receipt, storage, administration and disposal of medicines. Residents were treated with respect, privacy and dignity, during the caring process. NHS health care facilities and professionals had been accessed when required. Death and dying had been dealt with in a sympathetic and correct manner. All of the above had contributed to the health and personal care needs of service users being well met. EVIDENCE: Five service users, and eight relatives spoken to, all commented positively about the care being provided. Visitors told the inspector of the high standards being delivered compared to NHS facilities and other care homes recently accessed by their relatives. The service user plans and associated documentation seen was well written, meaningful and reflected the current condition of residents. The documentation seen and a discussion with both residents and staff members evidenced that health and personal care needs were being well met. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 12 A total of 4 care plans were examined in depth. NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. A local GP practice and pharmacy service the home, and there is a good working relationship with them. Records of their visits and outcomes were seen documented. Currently no resident/patient had a pressure area. The medicines within the home, medication administration records, controlled drugs book and drugs returned book, were all checked and no errors were noted. It was observed that a safe system was in place, and that the comprehensive medicines policy documentation seen was being complied with. The documentation seen evidenced that only trained nurses administered medicines. No resident was ‘self medicating’, but locked facilities were available. Controlled drugs were checked and the stock reconciled with the accurate records seen. The new system of drug disposal, including controlled drugs, had recently been introduced. During the inspection it was observed that privacy and dignity were being afforded to residents, and there was very good interaction with staff. Care staff were seen knocking on doors before entering. Four residents told the inspector that they were treated with respect, and that the staff were very kind. The records and policy documentation seen, along with a discussion with the staff, evidenced that death and dying aspects had been dealt with correctly and in a sympathetic manner. There had been 10 deaths in the home during the previous 12 months. During this period the home had nursed very poorly patients with terminal illness, and this had reflected in the total number of deaths recorded. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 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): Standards 12,13,14,15 Residents were satisfied with their lifestyle in the home, and they had been able to exercise choice and influence decisions affecting them. Contact had been maintained with relatives and friends of residents. Opportunities to access the local community had been made available. Activities took place but the coordination and recording could be improved. Catering aspects were good with balanced nutritious meals being served, along with resident consultation and choice. All of the above had contributed to the high level of satisfaction expressed by service users during the inspection. EVIDENCE: Several residents told the inspector that their views had been listened to, and that they had been able to influence some aspects of the running of the home e.g. mealtimes, menus. These comments had been documented along with the feed back from the resident/relatives questionnaires, and they had been acted upon. Contacts had been maintained, where possible, with relatives and friends and this was seen documented. Residents spoke of their visitors and their involvement with the home. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 14 Visitors attending the home during this inspection, told the inspector of the good links and communication with them. Trips out to the community had previously been organised and transport provided. A designated person should be employed to coordinate and record the activities and entertainment provided. Two residents commented that this would be appreciated. It was noted that no summer fair had taken place this year, possibly due to the lack of organisation by a designate person. Several residents spoke of their satisfaction with the meals and choices offered. The menus and catering records were examined and evidenced that the dietary requirements of residents were met. The records evidenced that residents’ needs with diabetes, and special diets, had been met. The cook when asked said that fresh good quality food from local suppliers was delivered on a weekly basis, the records seen confirmed this. Adequate supplies of fresh vegetables and fruit were also seen. The mid day meal seen was well presented and met all nutritional requirements. The care staff spoke with each resident on a daily basis to establish his or her choice of food for the day, and this was seen documented. The inspector sampled the mid day meal and it was very good, meeting all requirements. Several residents were unable to make a decision regarding choice of meal, due to their current condition, and the inspector saw them being assisted by staff who were knowledgeable of their likes and dislikes. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 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): Standards 16,17,18 Complaints or grumbles are listened to and resolved. No complaints had been received by the home or CSCI, since the last inspection. The home policies, procedures and staff training, protected residents from aspects of abuse. Service users legal rights were protected. Cards and letters from appreciative relatives/representatives containing compliments on the home evidenced their satisfaction. EVIDENCE: An examination of the complaints record, the relevant policy and procedure documentation, and a discussion with staff and residents, evidenced that complaints and grumbles were listened to and dealt with. Since the last inspection no complaints had been recorded or brought to the attention of this commission. Many ‘thank you’ and complimentary cards were seen from appreciative relatives. No incidents of neglect or abuse of any kind has been reported. The policy documentation seen, and a discussion with staff confirmed that residents are protected from all forms of abuse. Documentation seen evidenced that the above issues had been discussed at length during staff induction, training and on-going supervision. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 16 A discussion with the staff and residents evidenced that all residents had been afforded the opportunity to exercise their vote in past elections. The manager confirmed that an advocate would be facilitated if required by a resident. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,23,26 The home is fit for purpose and provides a safe environment for residents. The home was clean, warm and tidy, and had a very comfortable atmosphere. The buildings and grounds and gardens were well maintained. Increased single bedroom occupancy is being considered. The above has contributed to the satisfaction of the premises as expressed by the residents and their relatives. EVIDENCE: A tour of the building, and a check on the maintenance documentation, verified that the premises were fit for purpose, clean warm and tidy, and were being well maintained. It is understood that in the long term an increase in single bedroom occupancy is being considered. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 18 The duty rosters evidenced that adequate ancillary staff were employed. Staff when asked told the inspector of their knowledge on infection control, and showed him the relevant documentation. Adequate hand washing facilities, including hand gel, were available throughout the home. The laundry and sluice facilities were seen to be fully compliant. The records evidence that maintenance of the premises was being given a high priority. The grounds and gardens were seen to be well maintained and were much appreciated by residents, visitors and staff spoken to. Hot water temperature checks, and emergency lighting/fire alarm tests were seen up to date and correct. There are no outstanding issues known from the Fire Prevention or Environmental Health departments. The EHO previously reported items in the main kitchen had been addressed. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30 The assessed needs of service users had been met by an adequate number of suitably trained staff. Training had been given a high priority and 66 care staff had achieved NVQ level2, or above. Recruitment procedures had been correctly addressed which had contributed to the protection of service users. It was adjudged that staff were provided in sufficient numbers, and had sufficient knowledge and skills, to protect service users and meet their assessed needs. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 20 EVIDENCE: The registered care manager (RGN) was in charge of the home accompanied by two more registered nurses and five care assistants. Ancillary staff on duty included; cook and catering assistant, two domestic staff, laundry worker, maintenance/ gardener, and a business support worker. These staffing levels were adequate to meet the needs of current 25 residents in the home. The duty rosters seen, and a discussion with the care manager and the staff, evidenced that adequate numbers of staff had been on duty to meet the needs of the existing service users. The following care staff had been on duty or exceeded for the 25 residents; a.m. 1RGN 4 Care assistants ( Care manager RGN for 5 days), p.m. 1RGN 3 Care assistants, nights 1RGN 1 Care assistant. (awake on duty) Adequate ancillary staff had been provided each week. Six residents asked stated that staff were available when they wanted them, and that the staff were capable. The records seen evidenced that in addition to the registered nurses the home employed 15 care assistants, of which 10 (66 ) were trained to NVQ level 2 or above. The records evidenced that induction and NVQ training had been given a high priority. General training had also been given a high priority and the training records of individuals were seen. The records evidenced that care assistants had benefited from ‘in house’ and external training, which had covered the needs of the registered client group. Staff told the inspector that they had been afforded the time off and encouraged to study. The homes recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. Staff asked stated that they had job descriptions and contracts of employment. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,38 The home appeared to be well managed by an experienced manager. An open positive and inclusive atmosphere was evident within the home. Quality assurance was in place, but the recording of regular supervision sessions should be improved. Financial aspects were correctly addressed and recorded, with safeguards to residents. Health and safety issues had been given a high priority and managed well. All of the above had contributed to the home being run in the best interest of service users. EVIDENCE: The registered care manager is well experienced. Her deputy is well qualified including the Registered Managers Award. An open, positive and inclusive atmosphere was observed during the visit and confirmed to the inspector by service users, staff and relatives. Staff when asked also said the manager portrayed a clear sense of leadership and direction which enabled them to relate to the aims and objectives of the home. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 22 From observations made, discussions with service users and staff, it was evident that the home was being run in the interests of service users. Quality assurance, including feedback from residents and their representatives, was seen documented. Documentation seen evidenced that the views of visiting professionals had also been established, and included in the review process. The documentation for the nursing and care staff supervision sessions, six times per year, should be improved as agreed. A check on the records and a discussion with both residents and representatives evidenced that all service users had the opportunity to handle their own finances and residents and families had chosen to do so. Day to day monies of residents were checked and money held reconciled with the ledger. Inventories of valuables and belongings brought into the home were seen recorded. No health and safety issues were noted during this inspection, including a tour of the home. The documentation seen for checks and examination of plant and equipment was all correct and up to date and included; fire precautions, fire equipment, gas testing, boiler servicing, wheelchairs, equipment, hoists, lifting equipment, shaft lift servicing and tests, electrical installation tests, portable electrical appliances, water treatment, water temperatures. The maintenance person and other staff spoken to confirmed that health and safety issues are given a high priority. The care manager and a committee member gave assurances that the home was viable and that the association adopted suitable accountancy and budgeting procedures. The current public liability insurance certificate was seen up to date and correct. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 3 18 3 3 x x x x x x 4 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 2 1 Refer to Standard OP36 OP12 Good Practice Recommendations The documentation of formal staff supervision sessions should be improved. A designated person should be employed to coordinate and record the activities and entertainment provided. Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Kirk House Nursing Home DS0000022345.V252175.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!