Inspection on 04/06/07 for Kirkdale Nursing Home

This inspection was carried out on 4th June 2007.

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 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 10/01/07

Kirkdale Nursing Home 04/05/06

Kirkdale Nursing Home 28/11/05

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 Katherine Acheson Key Unannounced Inspection 11:00 4 and 5th June 2007 th 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.V340397.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. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 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.V340397.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 8 places can be used for people with dementia aged 50 . 10th January 2007 Date of last inspection Brief Description of the Service: Kirkdale is a modern, purpose built facility that is registered to provide personal and nursing care to thirty-eight older people with dementia. The home is single storey. The home is divided into two units, Lavender and Rosemary. Each unit has three lounge areas and a link lounge in addition to a dining room. Bathing and toilets are available on each unit. Bedrooms in the home environment are single in nature and meet the required amount of space. Bedrooms do not have en-suite facilities. Externally there are surrounding grounds and a pleasant enclosed garden/seating area for resident use. Car parking is available at the home. The home is on a bus route and close to Stockton town centre The cost of care at the time of the inspection visit ranged from £497 to £547 per week Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection of the home was carried out over two days, the 4th and 5th of June 2007. On the first day of the inspection the Inspector arrived unannounced. The Manager of the home was aware of the second day of the inspection. On the 4th June 2007 the Inspector arrived at 11am and left at 5pm. On the 5th June 2007 the Inspector arrived at 10:30am and left at 1pm. Discussion with residents was difficult due to their dementia, however three residents were spoken to briefly. Five relatives were spoken to during the visit. The homes House Keeper and Cook were spoken to and lengthy discussions also took place with the Manager and Deputy Manager of the home. The reason for the inspection was to see how good a job the home does in meeting the National Minimum Standards set by the government for Care Homes. Numerous records including care plans, menus, complaints and staff recruitment and training records were examined. The Inspector walked around the home with the Manager. Requirements identified at the last inspection in January 2007 were re-visited. The details of any issues identified at this inspection requiring action are to be found at the back of this report. What the service does well: Good recruitment procedures are in place. Appropriate checks are carried out before a staff member starts working at the home. Appropriate activities are provided for residents Relatives spoken to during the inspection in general expressed their satisfaction at the care received. Comments made included, “The Manager is very good and the care is second to none” “Nothing is a bother” “It’s like being part of a family it’s a welcoming place” Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The homes hard wiring, periodic inspection of electrical installation servicing is out of date. The Registered Person must ensure that this is serviced every five years. Since last inspection an area of the home, which had been previously used as a day centre, is now being used as a training suite. Staff and members of the public use the training suite. Although people using the training suite do not need to access resident areas it is felt that inappropriate security systems are in place to ensure resident protection. Water temperatures in resident areas are not monitored on a regular basis; the Registered Person must take action to address this. The homes complaint procedure needs to be updated to include all of the required information and the recording of complaints could be better. The dining room carpets within the home are extremely marked and stained and need replacing. Action needs to be taken to ensure that medication is stored at correct temperatures and that a record of unused medication returned to the licensing company is kept. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Kirkdale Nursing Home DS0000000182.V340397.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 Kirkdale Nursing Home DS0000000182.V340397.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of prospective residents are carried out to ensure that the home can meet their needs. EVIDENCE: Before going into Kirkdale, residents are assessed by a Social Worker or health care professional. A copy of this assessment is forwarded to the home for the management to look at. Staff at the home then carry out their own pre-admission assessment either visiting the person in their own home or at hospital to ensure that the needs of the resident can be met at home. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 10 Two residents files were looked at during the visit, both of which contained an assessment of needs and evidence of personal choice. Kirkdale does not provide intermediate care so standard 6 is not applicable to this home. Kirkdale Nursing Home DS0000000182.V340397.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that residents receive is based on their individual needs. Care plans are detailed, which will help to ensure that resident’s needs are met. Some improvements are needed in respect of medication storage and record keeping to ensure safe practice. EVIDENCE: Two residents plans of care were looked at during this visit. Care plans contained detailed information about the resident and the help they needed. Likes, dislikes and personal preferences were recorded. Care plans showed clear evidence of choice. One plan of care detailed how a resident liked to carry a handkerchief with them at all times. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 12 Care plans had been updated on a monthly basis and included any deteriorations or improvements made. Care plans showed evidence of regular visits from G.P’s, District Nurses, Dentists, Opticians and the Chiropodist. Three residents and five relatives were spoken to during the inspection comments made in respect of care provided included, “On the whole they do a fantastic job, especially the care workers” “It is very good” “The carers are very good nothing is too much bother” “All the staff are very good from the House Keeper to Care Assistants to the Manager” “They listen but I feel I have to suggest first. The home never come up with the idea first” “Staff are fabulous” “I like the fact that the home is on one level and residents have the freedom to walk about” The Manager advised that since last inspection a Physiotherapist has been appointed. The Physiotherapist has begun to spend time with those residents who have limited movement to carry out passive exercises. The Physiotherapist is also offering advice on how best to ensure the comfort and posture of residents who are immobile. During the visit a medication audit of one of the residents files sampled during the inspection was carried out. Medication administration charts had been completed correctly and the stock balance of medication belonging to the residents was correct, matching up with medication ordered, received, administered and remaining in the home. The last inspection of the home highlighted that staff at the home must keep a record of all unused medication that is returned for destruction, this had not been addressed. The last inspection also highlighted that the medication room was too warm. Records looked at during this inspection highlighted that this was still a problem. The Manager said that efforts have been made to lower the temperature by boxing in pipe work and that an estimate had been obtained Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 13 for air conditioning, however due to the situation of the medication room this was not possible. Quotes are now being obtained for other cooling systems. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate and enjoyable activities do take place at the home and residents are supported to practice their religion. Visitors are encouraged and made to feel welcome at anytime, all of which help to ensure fulfilment and contentment. EVIDENCE: The home does not employ an Activity Co-ordinator. Care staff plan and provide activities for residents. Activities mentioned included skittles, reminiscing and arts and crafts. Discussion with the Manager and relatives highlighted that a number of residents were unable to join in activities provided due to their dementia, however such residents benefited from pamper sessions and gentle exercise provide in the form of passive exercises. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 15 An Aromatherapist visits the home every other week and sees up to five residents each time. Relatives spoke of recent entertainers coming into the home one being an Elvis impersonator and someone else who plays the guitar and sings. One relative spoke of a recent outing to the local pub to celebrate a resident’s birthday. A number of residents had enjoyed a pub lunch and drinks. Contact with family and friends is encouraged and that visitors are made to feel welcome at any time. Relatives spoken to during the visit said, “You can visit when ever you want my son stayed until 11pm last week” “You can visit at any time” “It’s like being part of a family it is a very welcoming place” The Manager said that residents are supported to practice their religion, the Special Minister from the local Roman Catholic Church visits each Wednesday to give those residents who wish communion. Representatives from the local Church of England Church visit every month in which some residents participate in the short twenty-minute service. The home employs a hairdresser for which there is no charge. During the inspection a discussion took place with the homes Cook. It is evident that since last inspection improvements have continued in respect of the food provided. Lot of home baking was evident with a plentiful supply of cakes and biscuits. Residents and relatives spoken to during the inspection said, “My husband enjoys the food that he eats” “I have a can of John Smiths every lunch time” “The home made food is superb, the cakes are superb”. It was highlighted at the last inspection that consideration should be given to providing fresh fruit and vegetables. Discussion with the cook highlighted that in general frozen vegetables were still being used. The cook said that she was finding it difficult to arrange a supplier of fruit and vegetables to deliver to the home. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 16 Three out of five relatives spoken to during the visit said that residents didn’t get a lot of fresh fruit and that they brought fresh fruit into the home for their family member. One relative said, “They occasionally get a banana and custard, but most of the time it is tinned fruit. I bring in strawberries and prunes”. Another relative said, “I often bring in a banana and apple”. The Manager said that she would address this area with the cook and ensure that residents are provided with fresh fruit and vegetables. The Manager said that the lunchtime of residents has been reviewed. It was highlighted at the last inspection that there appeared to be insufficient staff to assist with the feeding of residents at lunchtime. An additional member of staff now comes on duty at lunchtime to assist with feeding. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 16 and 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents and relatives are encouraged and supported to make any complaints they feel necessary, however the homes complaint procedure does not advise of appropriate steps to follow. Adult protection procedures are in place, which helps to protect residents from abuse. EVIDENCE: The homes complaint procedure has been reviewed since the last inspection, however does still not meet the required standard. The Manager advised that in the first instance residents/relatives should make their complaint to the Manager and if it were not resolved then the complaint would go to the second stage with either the Trustees or the General Manager dealing with the complaint. The complaint procedure needs to be updated to include clear stages, who to contact, including name address and telephone number and timescales for the process. The complaint procedure should be updated to include residents and relatives all of the funding authorities and right to complain. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 18 Relatives spoken to during the inspection said that they would feel comfortable in raising any complaint with the Manager. Records examined during this visit showed that there has been one complaint in the last twelve months. It was noticed that the recording of complaints is not structured or clear. The complaints record does not include the nature of the complaint, details of investigation, action taken or if the complaint was substantiated or not, a discussion took place with the Manager in respect of this. The homes adult protection procedure has been developed in line with the Department of Health guidance. No Secrets. Records were available to confirm that staff had received training in adult protection and signs and symptoms of abuse. There have been three adult protection referrals in the last twelve months, all of which have been dealt with appropriately by the home. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 19, 20 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is improving providing the people who live there with and attractive, homely and comfortable place to live. Inadequate security arrangements at the home could compromise resident safety. EVIDENCE: During the visit a walk round of the home took place. It was pleasing to see that the home have continued with their plan of refurbishment. A number of lounge areas, both dining rooms and corridors have benefited from painting. The carpet in both dining room areas is extremely worn and Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 20 stained, however the Manager said that is to be replaced in the very near future. In general lounges were homely with appropriate furnishing throughout. Numerous bedrooms had benefited from refurbishment and numerous curtains had been replaced. A number of new towels and bed linen had also been purchased. Some bathrooms had also been painted, however consideration needs to be given within the plan of refurbishment to replace cracked tiling and deep clean or replace the stained flooring. The Inspector was informed during the inspection that an area within the home that had previously been used as a day centre for people with dementia was now a training suite. The training suite is used by both employees of the home and members of the public. The Commission for Social Care Inspection should have been informed of this change prior to it taking place. The Inspector was informed that access to the training suite is by the main entrance. A Training and Development Administrator is based in the training suite during working hours. People attending training use the internal intercom system to gain access to the building and do not need to access residents areas but once in the main building there is no further security to ensure resident safety. It was also noted that the training suite looks out onto a main corridor area in the home and is not screened. Immediate action must be taken to address both areas. Since last inspection the home has employed a House Keeper. The inspection highlighted numerous improvements in respect of general cleanliness. On the day of the inspection the home was clean and odour free. Appropriate laundry facilities are in place. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff at the home are trained and staffing levels reflect the needs of people living at the home. EVIDENCE: There were thirty residents residing at the home at the time of the inspection. Staffing rotas examined informed the inspector that there were six care staff on duty on a morning, five on an afternoon, seven on an evening and three on night duty. In addition to two trained nurses on duty day from 8am until 9pm and one on a night. Seven care staff are available between the hours of 1pm and 2.30pm to help at lunchtime to assist those residents who need help with feeding. The Manager of the home works full time. She said that for three days a week either she or the Deputy Manager is supernumerary and work in addition to the staff numbers above. Some additional staffing is provided to a number of residents who require one to one support. This support in the main is provided by agency staff that have worked at the home regularly and know the residents well. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 22 Of the five relatives spoken to during the visit three relatives felt that there were not always enough staff on duty to meet the needs of residents. Two relatives said that although staff were busy they did feel that there were enough staff on duty. The Manager said that the Management team of the home had reviewed staffing and had made some changes since last inspection and that they would continue to monitor dependency of residents. The Manager said that 44 of care staff working at the home have achieved an NVQ level 2 in care. The homes recruitment procedure is robust. The files of two newly appointed staff were looked at during the visit. Evidence was available to confirm that appropriate Criminal Record Bureau checks are carried out before staff start working at the home. Both files examined contained all of the required information including, proof of identity, photograph and two references. Records were available to confirm that new staff receive induction training, however as highlighted at the last inspection this does not meet with induction standards set by Skills for Care. The Manager advised that the homes induction has been reviewed and is awaiting approval from Trustees at a meeting arranged at the end of June 2007 and once agreed will be used for all new staff. Records were available to confirm that new care staff working at the home are receiving in house induction, which includes areas of health and safety specific to the home. Recent training provided to staff working at the home has included moving and handling, fire and wound management. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 31, 33, 35 and 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The Manager of the home is both qualified and experienced, quality assurance systems are in place to ensure that the home is run in the best interest of residents. In general the health and safety of residents is promoted, however out of date servicing and failure to follow Health and safety guidelines could put residents at risk. EVIDENCE: The Manager is a Registered Psychiatric Nurse who has worked in the nursing and social care environment for many years. The Manager has achieved a management qualification. The Manager advised of training she had Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 24 undertaken during the last twelve months this included training on The Mental Capacity Act, catheterisation and adult protection. Standard 36 was not inspected in full, however a recommendation highlighted at the last inspection in January 2007 was re-visited. The Manager advised that she has set up a system to ensure that all staff receive formal supervision on a regular basis. Quality assurance and quality monitoring practices are in place. Surveys are sent out to residents/relatives on an annual basis to see if they are happy with the home and care that is provided. A discussion with the General Manager of the home highlighted that surveys for 2007 are to be sent out in July, which is a little later than last year. The reason given for this is that the home has made a number of changes one of which is the appointment of a Housekeeper. The General Manager advised that she wanted to give the changes made enough time to see if they make a difference and hopefully this will be fed back via the surveys. Following this all surveys are to be reviewed and comments acted upon. The home holds residents and relatives meetings; minutes were available of the last meeting in March 2007. The Manager said that as a result of their dementia residents are unable to manage their own finances. Those residents who want a small amount of change in their pocket do so. The home does not handle the personal allowance for residents, relatives/representatives or Social Services maintain control. Records were examined to confirm that the Gas boilers and fire extinguishers had been serviced within the last year. The Manager said that a rolling programme of servicing of appliances and equipment is in place. It was highlighted at the last inspection in January 2007 that the fixed electrical installation servicing was out of date and as such required servicing, this had not been actioned. It was also highlighted that the Registered Person must give consideration to the Health and Safety Guidelines to monitor bath and shower water temperatures weekly. Records looked at during this visit confirmed that water temperatures were tested in March and May 2007. Tests of the fire alarm system are carried out on a regular basis. The Manager advised that since last inspection that portable appliance testing had been carried out. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 25 Following this inspection a discussion took place with the home’s General Manager regarding concerns in respect of water temperatures not being monitored on a regular basis and the fixed electrical installation not being serviced. The Inspector was informed that steps had been taken immediately after the inspection to get quotes and arrange servicing of the fixed electrical installation and that the Line Management of the home are to ensure water temperatures are to be monitored regularly. Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 27 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 OP9 Regulation 13 • Requirement The Registered Person must address the problem of the medication room being too warm to ensure resident wellbeing The Registered Person must ensure that a record of medication returned for destruction to the licensing company is kept and available for inspection to ensure an audit trail of medication is maintained Timescale for action 04/06/07 • Previous timescale for action of 15/01/07 not met 2. OP16 22 The complaint policy/procedure must be updated to include clear stages, contact details including name address and telephone number and timescales for the process to ensure everyone is aware of correct procedure to follow Previous timescale for action of 28/02/07 not met Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 28 31/07/07 3 OP38 23 • • The Registered Person 04/06/07 must ensure that the fixed electrical installation (hard wiring is serviced every five years The Registered Person must give consideration to the Health and Safety Executive Guidelines to monitor bath and shower water temperatures weekly 4. OP19 16 Previous timescale for action of 15/01/07 not met The Registered Person must continue with their plan of refurbishment to make the home a pleasant place to live. • • This must include replacing the flooring in both dining areas The refurbishment of bathrooms must be given consideration when planning 2007/2008 budget this must include replacing cracked tiles and replacement flooring. 04/06/07 5. OP19 13 6. OP19 23 7. OP28 18, 19 The Registered Person must ensure that appropriate security arrangements are in place for residents living at the home to ensure resident protection The Registered Person must provide screening to the window in the training suite that looks out onto the main corridor in the home to ensure resident privacy The Registered Person must continue with their plan of action in which to achieve 50 of care staff qualified to NVQ level 2 in care. The Registered Person must ensure that all newly appointed DS0000000182.V340397.R01.S.doc 04/06/07 04/06/07 04/06/07 8. OP30 18 30/06/07 Page 29 Kirkdale Nursing Home Version 5.2 staff undertake induction that includes all common induction standards as set by Skills for Care. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP15 OP16 Good Practice Recommendations Consideration should be given to providing fresh fruit and vegetables The Complaints policy/procedure should be updated to include information of resident’s rights to complain to commissioning agencies such as Social Services and the Primary Care Trust. The homes statement of purpose and service user guide should also be updated to reflect such information The Registered Person should keep a clear record of complaints made. This should include nature of complaint, details of investigation, action taken and if substantiated or not 3. OP16 Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Kirkdale Nursing Home DS0000000182.V340397.R01.S.doc Version 5.2 Page 31 - 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. 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