Inspection on 28/11/05 for Kirkdale Nursing Home

This inspection was carried out on 28th November 2005.

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

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

Other inspections for this house

Kirkdale Nursing Home 06/10/09

Kirkdale Nursing Home 11/05/09

Kirkdale Nursing Home 20/05/08

Kirkdale Nursing Home 04/06/07

Kirkdale Nursing Home 10/01/07

Kirkdale Nursing Home 04/05/06

Kirkdale Nursing Home 20/06/05

Kirkdale Nursing Home 29/09/04

Kirkdale Nursing Home 15/04/04

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

CARE HOMES FOR OLDER PEOPLE Kirkdale Nursing Home Radcliffe Crescent Teesdale Estate Thornaby Stockton-on-Tees TS17 6BS Lead Inspector Julia Connor Unannounced Inspection 28th November 2005 12:20 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 Kirkdale Nursing Home DS0000000182.V267966.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. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kirkdale Nursing Home Address Radcliffe Crescent Teesdale Estate Thornaby Stockton-on-Tees TS17 6BS 01642 611199 01642 618899 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) Cleveland Alzheimers Residential Centre Mrs Christine Robinson Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 8 places can be used for people with dementia aged 50 . 20th June 2005 Date of last inspection Brief Description of the Service: Kirkdale is a care home providing nursing care for older people with mental health needs. It is a single storey purpose built home all bedrooms are for single occupancy; bedrooms are not en-suite. The bedrooms are a minimum of 10 sq.m. There are two dining rooms and several lounges. The home is on a bus route and close to the local town centre. Car parking facilities are provided. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried over two days. The first day the Inspectors’ arrived unannounced to the home. The Manager of the home was aware of the date for the second day of the inspection. The first day of the inspection was on the 28th November 2005 and commenced at 12.20 p.m. and concluded at 4.30 p.m. The second day of the inspection took place on the 6th December 2005 and commenced at 11.30 a.m. and concluded at 5.30 p.m. Four visitors’ and five members’ of staff were spoken to during the inspection. The residents’ were unable to state their views about the home due to their mental health diagnosis. The block paving area at the front of the property that had been identified during the June 2005 inspection had not been repaired. The block paving leading to the front door had also become uneven and consequently was a health and safety issue for all Residents’, visitors’ and staff. An immediate requirement was issued which required the Responsible Individual to take immediate action to make the area safe. No improvement had been made in regards to the recording in the Residents’ care documents since the previous inspection. The Inspectors’ were concerned that neither the commodes nor the lounge chairs had not been replaced since the last inspection. There were many areas within the home that required decorating. There were also areas within the home that had offensive odours. There were floor coverings that required a deep clean or be replaced. Three members of staff spoke to the Inspectors’ about training. Three confirmed that they had received training in Manual Handling and use of the hoist; two confirmed that they had received Fire training and one confirmed that she had received training about Health and Safety, which included COSHH. Six training files were audited; four staff had received mandatory training of Manual Handling, Fire and basic Health and Safety, which included COSHH. One member of staff had received training in Dementia care and two members of staff had received training in eye care for the elderly. It would be beneficial if more staff received training in dementia care. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Registered Manager should ensure that the information in the Residents’ care documentation is more detailed and the storage of medication is improved. The Registered Manager should ensure that the home is kept free of offensive odours. The Responsible Individual should ensure that a refurbishment and decoration programme is commenced as soon as possible. The Registered Manager should ensure that training is provided to the staff to ensure that they are able to carry out their role in caring for the Residents’. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 Page 7 The Registered Manager should ensure that the Cook commences dating decanted food and that systems are in place to ensure that any out of date food is discarded. The Registered Manager should ensure that 50 of the care staff are qualified to NVQ Level 2 or equivalent. The Registered Manager should ensure that the staff receives formal supervision six times a year. The Responsible Individual and Registered Manager should ensure that the homes policies and procedures are updated on a regular basis. 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. Kirkdale Nursing Home DS0000000182.V267966.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 Kirkdale Nursing Home DS0000000182.V267966.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): 4. The Residents’ have their needs assessed prior to their admission to the home, however there was no evidence that the Resident or their family member had been involved in the assessment process. EVIDENCE: Three of the Residents care files were audited and all contained assessments carried out by professionals working outside of the home. Pre-admission assessments had been carried out by staff from the home prior to admission. However, there was no documentation in place to show that the Resident or their family member had been involved in the assessment that took place. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 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 and 10 Residents’ care documentation does not reflect their current needs; nor does the care documentation contain sufficient/detailed information. The Residents’ are not protected by the home’s policies for the administration and storage of medication. There is a lack of consistency in the care the Residents’ receive. EVIDENCE: There has been no improvement in the recording within the Residents’ care documentation. Documentation had not always been reviewed within an acceptable time frame e.g. one Resident’s ‘day in the life of ‘ had not been updated since May 2003 and therefore did not reflect the current needs of the Resident. One Resident had a care plan for Diabetes but the plan did not specify what type of Diabetes, e.g. diet, tablet or insulin controlled. The daily recording for Residents’ was of a poor standard e.g. ‘settled day’ or ‘care continues’ is not an accurate record. One Resident had been identified as being at risk from falling and having episodes of aggression. There was no care plan in place for either of theses identified problems. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 Page 11 Due to the poor recording within the care documentation is was often difficult to track staffs decision making e.g. one Resident had a risk assessment in place for the use of bed rails. The risk assessment recorded that no bed rails were required. However, a later entry on the document stated that bed rails were in use but there was no recording of why this decision had been taken. A Resident had a Waterlow of 19 (a pressure sore risk assessment tool) which was defined as very high and would warrant at least monthly evaluations, however, this Resident’s risk assessment had only been reviewed three times in five months. During the audit of Residents’ care documentation the Inspector identified two accidents involving the hoist and the same Resident. The records were incomplete in respect of both accidents. Training files indicated that not all care staff had received manual handling training and those who had were not identified by the records available. There was no evidence of a review of the risk assessment documentation following these accidents. Care plans relating to wound care should be more specific, e.g. the size of the wound should be measured so that there is evidence that it is improving or not. There was no evidence in the notes that the Residents’ next of kin had been involved in the assessment or review process for their relatives care. On the second day of the inspection an audit of the medication took place. The Inspectors’ found that medication was not stored correctly e.g. staff were administering eye drops to Residents’ that had not been stored in the fridge. The Inspectors’ also identified that the controlled medication was not always disposed of when no longer required by the Resident e.g. medication had been stored in the Controlled Medication cupboard that should had been returned to the Pharmacy in August 2004. Medication disposal should comply with the requirements of the Department for environment, food and rural affairs (DEFRA). Following an audit of the controlled medication record book it was identified that one Resident had run out of his medication so the staff had used the same medication belonging to another Resident. This is not acceptable practice. One the first day of the inspection some of the Residents’ that the Inspectors’ met appeared unkempt e.g. Residents’ had food stains on their face and clothing and other Residents looked dishevelled e.g. hair not combed, underskirt hanging below skirts and no shoes or slippers on. Another Resident was wandering around the home dragging his Zimmer frame behind him. When this was pointed out to the Nurse in Charge he asked another member of staff to attend to the Resident. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 Page 12 Upon entering the home the Inspectors’ evidenced Residents’ sat in the dining room unaccompanied by a member of staff. On the second day of the inspection the Residents’ appearance had improved and staff were observed to be present with the Residents’. The Inspectors’ were concerned at this lack of consistency in the care provided. The family members’ who spoke to the Inspectors’ stated that they were happy with the care provided to their relatives and that in their opinion their relative was treated with respect and dignity. The staff were able to demonstrate during discussion that they were aware of the needs of the Residents’ and understood that although the Residents’ could not always voice their opinion or make an informed decision it was important that the Residents’ privacy and dignity was maintained at all times. Kirkdale Nursing Home DS0000000182.V267966.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): 13, 14 and 15. Residents’ maintain contact with family and friends; and are encouraged to exercise choice and control over their lives as far as they are able to. On the first day of the inspection lunch looked generally unappetising. On the second day of the inspection lunch looked appetising and well presented. EVIDENCE: On both days of the inspection there were visitors’ in the home. The visitors’ who spoke to the Inspectors’ stated that they were always made welcome by the staff. Due to the nature of their mental health problems the Residents’ were unable to voice their opinion of the home and the care they received. Family members’ stated that they felt that their relative was offered choice depending on their needs. Staff who spoke to the Inspectors’ stated that they knew the majority of the Residents’ well and so knew their likes and dislikes. However, the staff also stated that there were Residents’ who still had the ability to makes small choices such as what to wear. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 Page 14 On the first day of the inspection the lunch being served to the Residents’ was pork casserole, which looked generally unappetising not just the liquidized lunches. On the second day of the inspection lunch was ham, chips and tinned tomatoes, which looked appetising, well cooked and well presented. The Cook informed the Inspector that an alternative to the menu was available; visitors’ in the dining room confirmed this. The melamine cups ready to be used were stained. The state of the cups had been discussed with the Manager at the last inspection and at that time the Inspector had been told that the crockery was to be replaced; but it had not. When the state of the crockery was again discussed with the Manager the Inspectors’ were once more informed that there were plans in place to replace the crockery. On day two of the inspection the food served for lunch was observed to be more appetising and the Residents’ seemed to be enjoying their meal. Sandwiches were available as an alternative. On day two of the inspection there appeared more staff to give assistance to those Residents’ who required help. The Inspectors’ met the Cook on day two of the inspection and she informed them that a deputy Cook was about to commence employment at the home. The Cook was very enthusiastic and had plans to change the menus. An audit of the kitchen showed that there were areas for improvement e.g. dating decanted goods and ensuring that container lids had a good seal to prevent food being contaminated. Kirkdale Nursing Home DS0000000182.V267966.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): 18 Procedures are in place but need to be updated. Staff has not receive training, which would enable them to protect the Residents’ from any form of abuse. EVIDENCE: The home has a copy of the Teeswide Guidance regarding the Protection of Vulnerable Adults. The homes whistleblowing policy had not been updated since April 2003. An audit of the training files showed that no training had taken place regarding the Protection of Vulnerable Adults. Staff interviewed confirmed that they had not received training in this area, however all were able to describe the action they would take should they witness any form of abuse. The recording of potential adult protection issues should be improved to ensure that a detailed and accurate account is kept of the incident. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 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, 22, 24 25 and 26 The Residents’ do not live in a safe and well-maintained environment. The home is not clean, pleasant and hygienic. EVIDENCE: On the first day of the inspection the Inspectors’ made a tour of the building accompanied by the Nurse In Charge. The lounge chairs required replacing due to general wear and tear. This was identified in the June 2005 inspection report. Twenty-eight out of the thirty-eight commode chairs required replacing due to general wear and tear. This was identified in the June 2005 inspection report. Thirty-bedroom carpets required deep cleaning/replacing due to them being stained. Carpet cleaning was observed to be in progress in one bedroom. One Resident’s family member had replaced their relative’s bedroom carpet. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 Page 17 The carpets in both Rosemary and Lavender corridors continue to require replacing, including the corridor carpet outside of the dining rooms. The furniture in the reminiscence lounge was worn and needed replacing. The beds in five of the bedrooms were beginning to show signs of wear e.g. the covering of the base of one bed was starting to come away. In one bedroom a rusted tray was observed under the hand basin. In another bedroom there was a television which had a ‘failed do not use’ sticker. The footrests and seats of five wheelchairs were dirty and required cleaning. Three hoists were dirty and needed cleaning. There were areas of the home were offensive odours were present. There were towels that were showing signs of wear and would need to be replaced. There were three bathing areas that were cold, however the Inspectors’ were informed that windows would be closed and the areas made warm before a Resident was bathed. Three bathing areas had flooring that required a good clean. The bath in one bathroom was chipped. In the shower room there was an open bottle of shampoo that a Resident could have ingested. The Inspector asked the nurse to remove this hazard. The majority of the bedrooms had been personalised with photographs and ornaments by the Residents family members. The garden is well maintained. However, the paving at the front entrance is still cordoned off due to the paving being uneven. The block paving leading to the front door had also become uneven and consequently was a health and safety issue for all Residents’, visitors and staff. Therefore an immediate requirement was issued which required the Responsible Individual to take immediate action to make the area safe. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 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 Inspectors’ are concerned that insufficient staff were evident on the first day of the inspection to meet the needs of the Residents’. The duty rota indicated the appropriate number of staff where present in the home on both days of the inspection. It was of concern that there were fewer NVQ Level 2 qualified staff than at the last inspection. Staff are being trained to NVQ level 2 which should ensure that they can meet the Residents needs. The Residents are protected by the home’s recruitment practices. Staff do not receive training to keep them up to date with current care practises, which would assist them in delivering a good standard of care. EVIDENCE: During the two days of the inspection the Inspectors’ were told the required number of staff were on duty to meet the needs of the Residents. An audit of the duty rota showed that there were two qualified nurses and six care assistants on duty for the morning shift, one qualified nurse and eight care assistants on an evening shift and one qualified nurse and three care assistants on a night shift. However, due to the lack of consistency in caring for the Residents the Manager should review the dependencies of all the Residents to ensure that each Resident receives the care they require. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 Page 19 33 of the care assistants have their NVQ Level 2 in care. Three members of staff are currently working towards their NVQ Level 2. At the last inspection 40 of the staff had been trained to NVQ level 2. The Manager stated that the reason for the reduction in the amount of staff having their NVQ training was due to more staff having been employed. An audit of four personnel files showed that the home complied with the requirements stipulated in Schedule 2 of the Care Home Regulations 2001. The Inspector audited six training files. Four staff had received mandatory training of Manual Handling, Fire and basic Health and Safety, which included COSHH. One member of staff had received training in Dementia care and two members of staff had received training in eye care for the elderly. It would be beneficial if more staff received training in dementia care. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 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): 33, 34, 35, 36 and 38 There was evidence that quality assurance and quality monitoring takes place. Evidence of current financial viability has not been received by the Commission for Social Care Inspection. Staff at the home does not manage Residents’ financial affairs. Care staff does not receive regular formal supervision. Polices and procedures are in place but are out of date. EVIDENCE: There was no quality assurance/monitoring report available for the Inspector to read; the Manager stated that she thought that the General Manager was still analysing the feedback information. Regulation 26 reports are received by the Commission for Social Care Inspection. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 Page 21 The Inspector was informed that the home had had their Investors in People award renewed in September 2005. Evidence of current financial viability has not been received by the Commission for Social Care Inspection. The annual report that was sent was dated 31st March 2004. The Manager informed the Inspector that the Residents’ families take care of financial matters for their relative. An audit of six personnel files showed that regular formal supervision did not take place for example three staff had last received supervision in June, one in July and one in August. The sixth member of staff had a supervision document but it was not dated. The staff that spoke with the Inspectors’ stated that the Manager and nurses’ were always available for help and guidance. Policies and procedures were available but had not been updated e.g. the Infection Control policy and procedure had not been reviewed since February 2003. A random audit of the maintenance records showed that equipment was being maintained e.g. the alarm call had been checked in June 2005 and the Arjo bath hoist in July 2005. Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 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 X X X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 1 2 X 3 X 1 1 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 2 3 2 X 2 Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 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 3&8 Regulation 15 Requirement The plan of care must be drawn up with the involvement of the Service User, recorded in a style accessible to the Service User and signed by the Service User whenever able and/or their representative. THIS IS OUTSTANDING SINCE THE SEPTEMBER 2004 INSPECTION. In order to demonstrate the home’s capacity to meet the needs of each Service User, the registered person must ensure that there is a sufficiently robust individual assessment in place in the nursing documentation to determine such needs. THIS ISSUE OUTSTANDING SINCE THE SEPTEMBER 2004 INSPECTION. The registered person must make arrangements for the safe handling and disposal of medication in compliance with the Department for the environment, food and rural affairs (DEFRA). Timescale for action 31/03/06 2 7 15 31/03/06 3 9 13 31/01/06 Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 Page 24 4 5 15 19 & 38 16 13 6 19, 20 & 23 16 7 19 23 8 30 18 9 10 33 34 24 25 The registered person must provide suitable, wholesome and nutritious food. The registered person must make safe the entrance to the home by ensuring the paving slabs are even thus avoiding unnecessary risks to the health and safety of Service Users. THIS IS OUTSTANDING SINCE THE SEPTEMBER 2004 INSPECTION. The registered person must provide adequate furniture, bedding and other furnishings suitable to the needs of the Residents, as detailed in the body of the report. THIS IS OUTSTANDING SINCE THE JUNE 2005 INSPECTION. The registered person must ensure that all parts of the home are kept clean and reasonably decorated. THIS IS OUTSTANDING SINCE THE JUNE 2005 INSPECTION. The registered person must ensure that staff receive training appropriate to the work they perform including appropriate refresher training. The registered person must establish and maintain a quality audit system. The registered person must provide evidence of current financial viability. 31/12/05 Immediate 31/03/06 31/03/06 31/03/06 31/01/06 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000000182.V267966.R01.S.doc Version 5.0 Page 25 Kirkdale Nursing Home 1 2 Standard 27 28 The Manager should review the needs of the Residents’ to ensure that sufficient staff are on duty. The registered person should make arrangements for a minimum of 50 of care staff to be qualified to NVQ Level 2 or equivalent by 2005 The registered person should make arrangements for the staff to receive formal supervision six times a year. The registered person should make arrangements for the policies and procedures to be reviewed on a regular basis. 3 4 36 38 Kirkdale Nursing Home DS0000000182.V267966.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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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