Inspection on 04/05/06 for Kirkdale Nursing Home

This inspection was carried out on 4th May 2006.

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 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 Julia Connor Key Unannounced Inspection 4th May 2006 09:55 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.V292566.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 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.V292566.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 8 places can be used for people with dementia aged 50 . 28th November 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.V292566.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two Inspectors’ carried the inspection over three days. On the first day of the inspection the Inspectors’ arrived unannounced to the home. The Manager of the home was aware of the date for the second and third days of the inspection. The first day of the inspection was on the 4th May 2006 and commenced at 9.55 a.m. and concluded at 4.20 p.m. The second day of the inspection took place on the 18th May 2006 and commenced at 9.30 a.m. and concluded at 1.45 p.m. The third day of the inspection took place on the 23rd May 2006 and commenced at 9.30 a.m. and concluded at 12.30 p.m. Four visitors’ and two members’ of staff were spoken to during the inspection. One Resident was able to offer his opinion on the home and the care he received; the remaining Residents’ were unable to state their views about the home due to their mental health diagnosis. Four family members’ had completed their Relatives’ survey document. Three Relative/Comment cards were returned. On the first day of the inspection the Inspectors’ evidenced that six Resident surveys and six Relative/Visitor comment cards were still to be given out by the Manager or her staff. On the third visit to the home the Inspectors’ were given another two Resident survey documents and one Relative/Visitor comment card. During the first day of the inspection an anonymous concern was logged with the Commission for Social Care Inspection. The areas of concern discussed were the poor level of hygiene within the home, offensive odours, the state of the furniture in bedrooms and lounges, food being served cold and the lack of activities. The Inspectors’ evidenced all of the above concerns during the inspection process. A complaint made by a family member was reluctantly made available by the General Manager to the Inspectors’. Having read the letter of complaint the Inspectors’ informed the Manager and General Manager that they intended to take forward the matter as an adult protection referral, which the Inspectors’ felt should have been the action of the General Manager upon receiving the complaint. Requirements remain outstanding from the September 2004 and June 2005 inspection reports. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 6 On the first day of the inspection the Inspectors’ gained entry to the home without a member of staff meeting them at the front door to check their identities. On the second and third visit to the home, when the Inspectors’ were expected a member of staff met them at the front door and took them to the Manager’s office. A family member who spoke to the Inspectors’ informed them that she had difficulty in gaining access to the home and often had to knock on the kitchen window to gain entry. 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. The Responsible Individual should ensure that the refurbishment is continued and a decoration programme is commenced as soon as possible. The Registered Manager should ensure that the home is kept clean, hygienic and free of offensive odours. 50 of the care staff should be qualified to NVQ Level 2 or equivalent and should receive formal supervision six times a year. The Registered Manager should ensure that the Cook keeps the food warm whilst being served to the Residents’. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 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. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 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.V292566.R01.S.doc Version 5.1 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): 3 and 4 The Residents’ do not always have their needs assessed prior to their admission to the home; nor was there evidence that the Resident or their family member had been involved in the assessment process. EVIDENCE: Three care files were audited; there was evidence in two of the files that the home received information from the Social Worker or discharging ward regarding the Resident prior to them being admitted to the home. There was no evidence that the Resident or their next of kin had been involved in the assessment process. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Residents’ care documentation does not reflect their current needs; nor does the care documentation contain sufficient/detailed information. Medication is dispensed appropriately and Residents’ are protected by the home’s policies and procedures for dealing with medication. There is inconsistency in the care the Residents’ receive. EVIDENCE: The Manager informed the Inspectors’ that new care documentation was currently being implemented. One Inspector randomly chose three sets of Residents’ care documents. There had been little improvement in the recording within the Residents’ care documentation. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 11 Documentation had not always been reviewed within an acceptable time frame, for example, a nurse had recorded that one care plan would be reviewed every month yet the last review had been the 21st March 2006; the previous review had been the 6th October 2005. Therefore the plan did not reflect the current needs of the Resident. The entries made on the Residents’ daily recording sheet was of a poor standard e.g. ‘good diet’, ‘quiet day spent’ and ‘care needs met’ are not an accurate record of the care delivered to the Resident on that day. It was recorded that one Resident who had been aggressive ‘settled after treatment’, but there was nothing to say what the treatment had been. A new Resident to the home had an inadequate pre-admission assessment with no diagnosis and no care plans or risk assessments had been written. The information that was contained in the care file was not sufficient to meet the care, social or psychological needs of the Resident. The daily record stated that the Resident was wandersome but there was nothing documented regarding the intervention to take to help the Resident to settle. A general assessment had been completed for one Resident but no care plans formulated after care needs had been identified. This Resident became anxious and aggressive when care staff delivered personal care but there was nothing documented on the action the staff were to take to reduce the Resident’s behaviour. There was no evidence that the planned care for the Resident had been discussed with their next of kin. One visitor to the home stated that she was not kept informed regarding the care her relative received. However, another visitor to the home stated that she was kept up to date with her husband’s care. Four relatives who had returned the Relative/Visitor comment card had recorded that they were kept informed of important matters affecting their relative. The Inspectors’ were informed that the new policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines was with the Trustees’ for them to agree it. Regarding the disposal of controlled medication; the Inspectors’ were informed by the Deputy Manager that a record is kept of all controlled medication that is disposed of by the home. It was suggested to the Deputy Manager that a record is kept of all types of medication disposed of so that a medication audit trail could be carried out if necessary. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 12 On touring the building the Inspectors’ observed that the Residents’ were able to wander around freely and were appropriately dressed. One Resident who spoke to an Inspector stated that he was happy at the home, that the girls were lovely and that he felt he was treated with respect and dignity. One visitor to the home stated that her husband was cared for with respect and dignity and that his privacy was maintained. Another visitor to the home stated that ‘some of the carers’ could do with training as they were not very caring people’ that s/he did not feel welcome as the ‘carers are un-socialable’. This visitor went onto say that in his/her opinion ‘Christine is alright but does not supervise staff enough, staff just please themselves and quite often four staff sit smoking’. Another visitor to the home stated that the staff did not tell the Resident what they intended to do for example ‘they just put Residents’ in the hoist without telling them and Residents’ are frightened’. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Social activities do not take place on a regular basis within the home therefore Residents’ are not stimulated or their needs met. 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. The food served is often of an unacceptable temperature and Residents’ have to wait in turn for the staff to assist them to eat their meal. Residents’ do not eat in pleasing surroundings. EVIDENCE: Activities are not held on a regular basis, for example there had only been five recorded activities for the month of February, four for March and three for April, these activities included attending a church service, painting and drawing and for Easter an Entertainer and Easter bonnet making. When the inconsistency of the activities were discussed with the Manager she agreed that they needed to be more structured. There were visitors’ in the home on all three-inspection visits. One Resident had received her visitor in the privacy of her bedroom. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 14 One Resident informed the Inspector that he was happy at the home and that ‘the food was good’ and that ‘the girls are lovely’. His only concern was that there ‘not many people to talk to’ but he felt that he was treated with respect and dignity. Due to the nature of their mental health problems the remaining Residents’ were unable to voice their opinion of the home and the care they received. The Inspector who was present when lunch was being served observed that the hot lock was not plugged into the electric supply which resulted in the food not being as hot as it should be for example the fish cakes were only 49° and the chips were only 39°. The Inspector observed that a plate of food was left on the dining table for over ten minutes before being served to the Resident. When the Inspector touched the hot lock it was only warm. However, the Inspector was pleased to observe that one Resident was having a pint of beer with his lunch, which he was obviously enjoying. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Complaints are not investigated thoroughly and there are Relatives’ who are not confident that their complaints are taken seriously. There are procedures in place for the protection of vulnerable adults; however, management did not follow these procedures when informed of a protection issue. Residents’ are not protected from abuse. EVIDENCE: There is a complaint policy and procedure in place, which was updated in March 2006. A complaint made by a family member was reluctantly made available by the General Manager for the Inspectors’ to audit. Having read the letter of complaint the Inspectors’ informed the Manager and General Manager that they intended to take forward the matter as an adult protection referral, which the Inspectors’ felt should have been the action of the General Manager upon receiving the complaint. The recording of the complaint was of a poor standard for example there were no comprehensive notes taken and staff statements’ were not written or signed by the member of staff. There was no written feedback to the complainant to confirm what was discussed with them at the meeting between the General Manager and a Trustee. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 16 During the first day of the inspection an anonymous concern was logged with the Commission for Social Care Inspection. The areas of concern that the complainant discussed was the poor level of hygiene within the home, offensive odours, the state of the furniture in bedrooms and lounges, food being served cold and the lack of activities. The Inspectors’ evidenced all of the above concerns during the inspection process. The home has a copy of the Teeswide Guidance regarding the Protection of Vulnerable Adults. The homes own Protection of Vulnerable Adults and whistleblowing policy was updated in March 2006. The General Manager did not follow these procedures when informed of an allegation of neglect. There was no evidence that the staff had received training in the protection of vulnerable adults; however, the Manager stated that this training was due to be delivered soon. The care assistants’ who spoke with the Inspectors’ were able to describe the action they would take should they witness any form of abuse. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 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): 19, 20, 23, 24, 25 and 26. The Residents’ do not live in a safe and well-maintained environment that is clean, pleasant and hygienic. EVIDENCE: The Inspectors’ did not enter every bedroom as there were Residents’ being nursed in bed or receiving visitors in the privacy of their bedroom. The Inspectors’ made a tour of the building accompanied by the Nurse In Charge on day one of the inspection. Some lounge chairs had been renewed but there were still chairs that required replacing due to general wear and tear, as identified in the June 2005 inspection report. The Resident’s relative paid for bedroom carpets’ that had been renewed. The carpets in both Rosemary and Lavender corridors continue to require replacing, including the corridor carpet outside of the dining rooms. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 18 Eight new commodes’ were evidenced by the Inspectors’. The carpet in the Lavender lounge was stained and required a deep clean or possibly replacing. The carpet in the Rosemary lounge was stained. The Link lounge needs decorating. The small dining room carpet was stained. The large dining room also had a stained carpet and required decorating. The majority of the bedroom carpets are dirty and/or stained and require a deep clean or replacing. It was recorded in the quality audit report that a Relative had made the following statement ‘ carpets’ are becoming grubby’ and ‘ the carpets’ are very stained and need replacing or cleaned weekly’. 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. There were areas of the home were offensive odours were present; these areas’ were discussed with the nurse who accompanied the Inspectors’ on the tour of the home. There were towels and bedding that showed signs of wear and tear and need to be replaced. It was recorded in the quality audit report that a Relative had made the following statement ‘ the bedding has never been renewed for several years’. There was sheets’ on some beds that were stained and should have been sent to the laundry when the bed was made up by the staff. There were bathing areas were the flooring required a good clean and the walls required decorating. There were bathing areas’ that were being used for storage; some of the items looked like they should be discarded. It was recorded in the quality audit report that a Relative had made the following statement ‘ over the past year the standard of cleaning has dropped, cleaning is tidying only, no spring cleaning seems to be done’. Another relative had made the statement ‘place smells, which is normal, but you try to disguise this and I cannot stay in the home for more than an hour as it gets to my nose and throat’. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 19 The majority of the bedrooms’ had been personalised with photographs and ornaments by the Residents’ and their family members’. The garden is well maintained. However the Residents’ could not access the garden, despite the door being open, as there was a garden bench across the entrance. A relative who spoke to the Inspectors’ stated that it was a shame that the Residents’ could not access the gardens and s/he was concerned over the safety of Residents’ due to the bench being across the entrance to the garden. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 20 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 duty rota indicated the appropriate number of staff where present in the home on all three days of the inspection. Staff are being trained to NVQ level 2 which should ensure that they can meet the Residents needs. The Residents are not protected by the home’s recruitment practices. Staff do not receive sufficient training to keep them up to date with current care practises, which would assist them in delivering a good standard of care. EVIDENCE: An audit of the duty rota showed that the norm was for two trained staff to be on duty until 4 p.m. then one trained nurse for the late shift and night shift. The audit revealed that there was between five and seven care assistants each early and late shift. There are staff who are telephoning in sick on a regular basis, especially on a weekend, which resulted in the home having insufficient staff on duty. There were also shifts when there where more agency staff on duty than permanent staff, which was of concern for the continuity of care for the Residents’. There were times that staff were working an early shift then the night shift and then returning the same day to do an evening shift. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 21 The Manager had recorded in the pre-inspection questionnaire that 43.7 of the staff had an NVQ Level 2 or 3 in care. The home has done well to go from 33 to 43.7 in six months. An audit of five personnel files showed that the home did not comply with the requirements stipulated in Schedule 2 of the Care Home Regulations 2001, for example one personal file did not have the required two references. Four of the five personnel files audited contained evidence of minimal training. Two staff had received training in wound management, and three staff had received mandatory training, which consisted of manual handling, fire, health & safety and COSHH. The Inspectors’ were informed that staff had attended training in Dementia but there were no certificates or staff signatures to confirm the training had taken place. The Inspectors were also informed that a four-day First Aid course was scheduled for May. The Inspectors’ were informed that training in the protection of vulnerable adults was planned to be delivered in the next few weeks. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36, and 38. The Manager is a registered psychiatric nurse with many years experience of managing a nursing home. There was evidence that quality assurance and quality monitoring takes place. However no action appears to be taken when an area of concern is highlighted. Evidence of current financial viability has not been received by the Commission for Social Care Inspection. Staff at the home do not manage Residents’ financial affairs. Care staff does not receive regular formal supervision. The health, safety and welfare of the Residents’ are not promoted or protected. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 23 EVIDENCE: The Manager of the home is a registered mental nurse with experience of managing a nursing home. The staff spoke well of the Manager. One family member who spoke to the Inspectors’ stated that she liked the Manager. However, another Resident’s relative stated that ‘Christine is alright but does not supervise staff enough’. A letter to the Responsible Individual was sent requesting evidence of current financial viability, however, a response was not received by the time the draft report was sent to the home. The Inspectors’ where shown the latest quality audit report dated February 2006. One of the questions asked was ‘what do you think of the actual nursing home’? The response documented was ‘the gardens are very nice, but how are they used. The interior now is very shabby; the carpets are very stained and need replacing or cleaned weekly. The curtains are not fixed properly and are often hanging down. In some rooms the bedding has never been renewed for several years’. Another question was ‘do you find the nursing home staff helpful and friendly’? The response was ‘some are – but simple requests are rarely followed through – or messages passed on’. The full quality audit report can be accessed from the Manager of the home. The Inspectors’ were informed that the Residents’ families take care of financial matters for their relative. An audit of five personnel files showed that regular formal supervision did not take place. The Manager agreed that this was an area that still required action. Some policies and procedures have been updated this year for example the COSHH (control of substances hazardous to health) and Fire Safety policy was updated this year. The Manager had recorded in the pre-inspection questionnaire that the required maintenance had taken place for example the emergency lighting had been serviced on the 17th March 2006 and the fire equipment had been checked on the 23rd March 2006. There are commode chairs that require replacing as they are so stained and have ripped cushions. The Inspectors’ evidence dirty and stained carpets in bedrooms that had offensive odours. There were bedrail cushions that had faecal matter and dried blood on them. The Inspectors’ observed wheelchairs’ and bed tables that required cleaning. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 24 The Inspectors’ were informed that the commode pans were not being placed in the sluice machine to be clean and sanitized. This concern was discussed with the Manager who stated that the problem had been rectified and all commode pans were now being cleaned appropriately and hygienically. Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 25 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 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 2 X X 2 1 1 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 2 N/A 2 X 2 Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 26 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 OP3OP3 OP8OP8 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 arrange a progamme of actrivites having a regard to the needs of the Residents’ The registered person must provide suitable, wholesome and nutritous food which is at an appropraite temperature. The registered person must DS0000000182.V292566.R01.S.doc Timescale for action 31/07/06 2 OP7OP7 15 31/07/06 3 OP12OP12 16 31/07/06 4 OP15OP15 16 30/06/06 5 OP16OP16 22 31/07/06 Page 27 Kirkdale Nursing Home Version 5.1 6 7 OP18OP18 OP19OP19 OP20OP20 OP23OP23 13 16 8 OP19OP19 23 9 10 OP26OP26 OP27OP27 16 18 11 OP29OP29 19 12 OP30OP30 18 13 14 OP34OP34 OP31OP31 OP38OP38 25 13 ensure that any complaint made under the complaints procedure is fully investigated. The registered person must ensure that Residents’ are not placed at risk of harm or abuse. 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 keep the home free of offensive odours. The registered person must, having regard to the size of the care home and the needs of the Residents’ ensure that there are sufficent numbers of staff. The registered person must not employ a person until the appropraite checks have taken place – to obtain two references for each member of staff. The registered person must ensure that staff receive training appropriate to the work they perform including appropriate refresher training. The registered person must provide evidence of financial viability. The registered person must ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of Residents’ Immediate 31/07/06 31/07/06 Immediate 31/07/06 Immediate 31/07/06 30/06/06 31/07/06 Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP28OP28 Good Practice Recommendations The registered person should make arrangements for a minimum of 50 of care staff to be qualified to NVQ Level 2. The registered person should make arrangements for the staff to receive formal supervision six times a year. 2 OP36OP36 Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 29 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. Extracts may not be used or reproduced without the express permission of CSCI Kirkdale Nursing Home DS0000000182.V292566.R01.S.doc Version 5.1 Page 30 - 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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