Inspection on 06/02/07 for Kirkland House

This inspection was carried out on 6th February 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Kirkland House 23/02/06

Kirkland House 30/09/05

Kirkland House 14/12/04

Kirkland House 13/07/04

Kirkland House 17/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Kirkland House Queensway Yeadon Leeds LS19 7RD Lead Inspector Valerie Francis Unannounced Inspection 6th February 2007 10:15 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 Kirkland House DS0000033261.V322430.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. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirkland House Address Queensway Yeadon Leeds LS19 7RD 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) 01943 876392 Leeds City Council Department of Social Services Mrs Linda Christine Cox Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2006 Brief Description of the Service: Kirkland House is a large building situated in a residential area of Guiseley. The location offers a good bus service to Yeadon and access to the Guiseley shopping Centre. The building is a large detached purpose built care home for older people, which is owned and managed by Leeds City Council Social services. Kirkland House accommodates 31 older people on two floors. There are 31 single bedrooms. The first floor can be reached via a passenger lift. Toilets are strategically placed throughout the building, giving easy access to service users. There are four baths and a level access shower, which provides choice and support at the time of bathing. There is satisfactory parking at the front of the home. The provider completed and returned pre inspection information including the current charges, which range from £70.85 for local authority funded people to £458.86 for privately funded residents. Additional charges are made for chiropody, hairdressing, daily papers, toiletries, some activities and transport. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report brings together evidence gathered at this first Key unannounced Inspection visit to Kirkland House on the 6th February 2007 by one inspector over a period of 7.5 hours. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk During this visit discussions were held with residents, relatives and staff, records were examined and all areas of the home were seen. Comment cards were sent out to residents and their relatives to give people an opportunity to share their views of the service provided at the home with CSCI. Fifteen residents and five relatives responded, their views are included in the body of this report, and in the section that tells you what the service does well. A pre inspection questionnaire was sent to the home before this key inspection asking for information about the records, residents, staffing and the general running of the home, this was returned six weeks before the inspection. As part of this unannounced inspection the quality of information given to people about the care home was looked at. Residents were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide, statement of terms and conditions and the complaints procedure. The responses given by the residents seen during this visit were that some were aware, and others were unaware of a service user guide. Visiting relatives was aware of these documents. All residents knew who to talk to if they were unhappy about anything in the home Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The registered provider must make sure that there is a written outcome of the quality audit carried out of the service. The registered provider must make sure that the staffing levels during the day and at weekends are enough to provide residents with the care they need and taking into account the size and layout of the building. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 7 Staffing level at night of two staff must be given due consideration thus providing residents with more staff at a time when they are at their most vulnerable. The manager must make sure that all identified risk has a plan of action to be taken to manage or minimise the risk. The provider must make sure the carpet in the large communal sitting and hallway on the ground floor that is a potential trip hazard is replaced. The manager must make sure that reviewed care plans “Life Style Plans” do not have a lot of crossing out, and they are clear to follow and understand, if necessary a new form must be completed to record the reviewed plan of care. 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. Kirkland House DS0000033261.V322430.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 Kirkland House DS0000033261.V322430.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): 1, 3 and 4. (Standard 6 does not apply to this home). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home provides information for residents and/or relatives to make an informed decision about the home before they move in. The pre admission assessment information collected by the manager and staff ensures that there is an understanding of individual needs of residents, before they move to the home. EVIDENCE: Written information about services at the home is available to anyone interested in moving to Kirkland House. It gives detail information in a range of documents. These include a Statement of Purpose, and Service User Guide. They also provide a leaflet that gives basic information about the home and aspects of residential care for residents and their relatives. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 10 In most case the assessment that has been carried out by the placement agency, the “Easy Care” document is given to the home before admission, however this document does not contain enough information, the home uses this and their own assessment information to make a decision if they can meet the needs of the person. Before prospective residents move to the home, they are encouraged to come and visit, and spend the day at the home. This time is also used to introduce them and assess that their personal, health and social needs can be met by staff at the home. This information then forms the basis of a plan of care “Life Style Plan” for the resident when they move into the home. From discussion with staff they said they are provided with information about a new resident before they move in. A written life story of the resident, provided by family and friends helps staff to understand the resident and their social background. This is the basis of caring for the person as an individual. Kirkland House DS0000033261.V322430.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): 7,8,9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The health, personal and social needs of residents is met, in a way that maintains their dignity and independence. EVIDENCE: Visitors spoken to at the time of the inspection said that they had chosen the home after talking to the social worker and paying a visit to the home. They were able to have a good look around the premises and told about what care would be given they were also given a brochure. They also said that they were very happy with the way their relative had settled into the home and the good progress they were making. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 12 Three care files (“life Style Plans”) were looked at. Information seen related to the residents care, health and social needs. Plans seen were up to date with monthly evaluation and six monthly reviews, to ensure staff are providing appropriate levels of care and support to individual residents. One care plan seen had many changes when the resident care need had changed, however, with so many changes made it was somewhat difficult to follow, and the manager was advised that a new plan using a new document should be made, to prevent any needs being missed. She said it was the practice in the home to make a new plan when there were significant changes in care needs. Residents, their relatives and people involved in their care are invited to be involved in the review of care. In most case the care plans that identify any areas of risk for a resident has a plan of action put in place to minimise and manage the risk, whilst maintaining the persons independence. There was however one person who had a risk assessment for moving and handling but a plan of action was not in place. Residents spoken said that they had a special member of staff their key worker, who they can talk to and who call doctors and district nurses for them if they need them. The care staff who administer medication to residents are trained to do so, all have attended external training courses on the safe administration and management of medicines. A senior member of staff was observed giving residents their lunchtime medication. She followed the homes procedure; this ensures the correct medicine is given to the correct resident at the prescribed time. Medicines are stored safely, and checked to ensure they are correct when they arrive from the pharmacist. This reduces the risk of a resident’s medication being incorrect. Controlled Drugs are correctly stored in an appropriate cupboard. All controlled drugs are documented in hardback record book, which is signed by the member of staff administering and a witnessed by another. Throughout the day staff were observed providing support to residents in a way that maintained their dignity and independence. It was noticed that the staff and residents have very friendly with each other, without being overly friendly. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14, & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents spend their day as they choose and seeing whom they choose, when they choose. EVIDENCE: Visitors said that they could visit at any time and were always made to feel welcome. They are offered a hot drink by staff or able to make one using the upstairs kitchen area The atmosphere within the home was noted to be relaxed and homely The residents live active and varied lives. One service user went out for the afternoon to a day centre. Residents said that they enjoyed living at Kirkland House, one resident said “we have fun here”, another said “the staff are great” and another “we are well look after, this was also confirmed by visiting relatives. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 14 Monthly residents meetings are held, these meetings are used for residents to discuss matters relating to the running of the home, menus and activities. Residents are encouraged to maintain contact with family and friends, with the home encouraging relatives and friend to visit. Residents said that they enjoy their meals. Menus are planned with input from residents and staff. There is always a choice of food available. One resident said “ we can have something different if we do not like what is on offer on the menu”. The care staff carry out activities, by involving residents in games, exercise and current affairs. There is a notice board, which give the programme of activities for the month. Every day there is a range of group or individual social activities, which had been decide by the residents. From the CSCI survey information and from discussion with residents they said they could join in activities if they wish or they could spend their time doing what they like. Some residents spent their time in their rooms reading watching TV or listening to their radio. Residents choose to see their visitors in their bedroom or in the communal areas. Although there is not an activities co-ordinator employed at the home to engage residents in activities, residents did not appear to be bored or said they felt bored at anytime. Comments made by relatives in the survey information and at the inspection were positive, and also felt that the home cared for their relative very well. Three areas of the home are used by residents for dining, but the main dining area is near the central kitchen. Food for residents is served from a hot cabinets; this enables residents to see and smell the food before it arrives at their table. This may help to stimulate their appetite. All staff are aware of the importance to observe and report if a resident is not eating at set mealtimes. A nutritional risk assessment is carried out for any resident who is felt to be at risk of malnutrition. There is an area in each sitting room used by residents where cold drinks are available to the resident throughout the day. Snacks and hot drinks are available from staff during the day and at particular times and on request. Snacks are also available to resident during the night if they are hungry. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Residents can complain, and are safe from abuse. EVIDENCE: Posters are clearly displayed throughout the home about how to make a complaint. No complaint has been made since the last inspection. The manager said when a concern is brought to the attention of the management team this is dealt with quickly and efficiently. Residents said that if they had a complaint they would speak to their key worker or go to the office to speak to the manager or any of the officers, knowing that their complaint would be taken seriously and dealt with.” Staff have done training in recognising and reporting any allegations of abuse, to protect residents. Staff understood the term whistle blowing and who to talk to if they had concerns about poor practice within the home. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 16 Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The home is safe, well maintained and provides comfortable accommodation for residents. EVIDENCE: The home is situated in a residential area of Guiseley within easy reach Yeadon town centre, local shops and other shopping centres in the nearby areas. A tour of the building was undertaken which showed that the home in general was well maintained throughout. However, the carpet in the hallway and the large communal areas on the ground floor was seen as potential health and safety hazards. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 18 On the day of the inspection the carpet fitters were at the home sticking down the joint areas that were fraying. This area is well used by the residents, staff and visitors, the frying areas when loose could become a potential a trip hazard. All residents have single bedrooms those that were seen were well furnished and equipped with furniture and fitments belonging to the occupant. It would appear that residents have taken the opportunity to personalise their room reflecting their interests and hobbies. All bedroom doors are fitted with locks and a lockable facility is provided for service users to keep their belongings safe. There are a variety of communal sitting rooms through out the home. Two of the small sitting rooms were used a dining area and as quiet sitting rooms, these areas are comfortable and furnished in a style to suit the needs of the people living at the home. The home was noted to be clean and hygienic throughout. The garden is well maintained for the time of year. There are two kitchens in the home, the main and small one used by visitors, which is equipped with fridge and kettle. The laundry is equipped with a sluice cycle washing machine for sluicing soiled laundry. Although staff have had infection control training, the practice of sluicing soiled linen by hand is taking place and must cease to make sure that infection control is not compromised. There is a small laundry on the top floor, which has a domestic washing machine and dryer, which can be used by residents if they wish. A certificate to confirm that a specialist has examined the electrical hardwiring in the home, and it is safe, was seen. This reduces the risk of a fire in the home due to faulty wiring. Up to date records were in place for health and safety checks carried out for risk in relation to the premises. Plans are in place to compartmentalise areas on the ground floor in accordance with West Yorkshire Fire and Safety Authority recommendation Schedule 2 of the last inspection report. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. The procedures for the recruitment, deployment and training of staff are thorough, the number of staff available to residents at nights and sometimes during the day could be a risk to the people living and working there. EVIDENCE: At the time of the inspection there were two staff vacancies. One 37 hours care assistant and one 25 hours domestic. Both these post are being held for redeployment following a home closure. Presently these posts are covered by over times from the staff team. From records examined and following observation and discussion during the inspection staffing levels during the day are not always enough to meet the needs of the residents. At times during the evening and at weekends there are three members of staff available to residents. During the night the two waking night staff available is not enough for 31 residents. Staff appeared to work together as a team and relationships with residents were observed to be relaxed and friendly, with appropriate use of informality and humour. Staff were described as “friendly, nice and very good”. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 20 There is an induction training programme in place, and mandatory training for staff includes, fire awareness, first aid, health and safety, food hygiene, moving and handling and safe handling of medication. 55 of the care staff team have an (NVQ) National Vocational Qualification. There is a programme of NVQ training in the home to make sure that all staff have an NVQ qualification at some level. The staff recruitment files of three recently appointed care assistants were seen. All of the files contained CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) disclosures. Two written references, an application form and proof of identity were also in place. During discussion with staff they said enjoyed the training they received, and felt it helped them to provide good levels of care to residents. All staff are offered the opportunity to undertake a care qualification to help them develop good care skills. However many staff felt that training on mental health illness needs to be on offer, other than Dementia, for example people who has had a history of depression. There is a handover period at the end and beginning of each shift, where staff are given clear verbal instructions from the senior on duty, about the residents and what they are expected to do during their shift. This helps staff with their continuity of care to the residents. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Kirkland House is a well managed home where residents and staff are consulted about the standards of service. This makes them feel valued. EVIDENCE: The manager is experienced and qualified to carry out her role as the registered manager for the home. The home has a full management team, consisting of the registered manager and two care officers. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 22 An open and positive atmosphere was felt through out the inspection. Residents and staff are encouraged to contribute towards decisions about the home within the residents meeting and staff meetings. Residents’ monies held at the home are managed in a safe way, with evidence as to who, and how, residents monies is spent. Relatives are encouraged to manage the resident’s financial affairs. The personal allowance of one resident was checked and was accurate. There is a commitment to health and safety and safe working practices in the home. All staff have received mandatory health and safety training with regular updates. Fire drills are carried out on a regular basis and all staff receives fire safety training. Detailed risk assessments for the residents and the building are in place, which are reviewed and updated on a regular basis. Certificate were seen which showed compliance with electrical regulations. However the Gas Safety check was out of date. There was written evidence that regular servicing of equipment takes place to ensure the health and safety of residents and staff. This includes fire safety equipment, lighting, and electrical plugs. There is a quality monitoring system in place and residents, relatives and staff are consulted as to their views on the service provided at the home. However no written result has been published, the manager said verbal feedback has been given to residents, relatives, and staff at their respective meetings. Regular residents and staff meetings are held where any issues relevant to residents and staff are discussed, and notes of these meetings are taken and s available to anyone who did not attend. Staff receive regular supervision. This provided the Manager and care officers and staff member, with an opportunity to discuss their effectiveness to do their job, and agree future training to improve their skills to care for residents. Staff receive regular training in the safe moving and handling to ensure they are competent to move residents using special equipment. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 2 X 3 X X 2 Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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 OP27 Regulation 18 Requirement The registered provider must make sure that the staffing level during the day and at weekends is enough to meet the care needs of the people living at the home taking into account the size and lay out of the building. Previous timescales 20/12/05 and 30/06/06 Staffing level at night of two staff must be given due consideration thus providing residents with enough staff at a time when they are at their most vulnerable. The provider must provide the CSCI with a timescale when this matter would be resolved. The registered manager must provide residents and other with written feedback for survey carried out. Previous timescales 15/05/06 The manager must make sure that all identified risk has a plan of action to be taken to manage or minimise the risk. Timescale for action 25/03/07 2. OP27 18 30/03/07 3. OP33 24 25/03/07 4. OP7 13 25/03/07 Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 25 5. OP7 23 The provider must replace the carpet in the large communal sitting area and hallway on the ground floor, so that the health and safety of residents and others are not compromised. 20/03/07 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 OP7 Good Practice Recommendations The manager must make sure that reviewed care plans “Life Style Plans” do not have a lot of crossing out and it is clear to follow and understand. And if necessary a new format to record the plan must be made. Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Kirkland House DS0000033261.V322430.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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