Inspection on 04/03/08 for Kirklands

This inspection was carried out on 4th March 2008.

CSCI found this care home to be providing an Adequate service.

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

Kirklands 04/06/09

Kirklands 25/02/09

Kirklands 07/03/07

Kirklands 23/03/06

Kirklands 28/06/05

Kirklands 14/03/05

Kirklands 09/09/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Clover House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Kirklands Sullart Street Cockermouth Cumbria CA13 0EE Lead Inspector Diane Jinks Unannounced Inspection 4th March 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kirklands DS0000022641.V356196.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. Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirklands Address Sullart Street Cockermouth Cumbria CA13 0EE 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) 01900 822364 sharon.blackwell@anchor.org.uk Anchor Trust Mrs Maureen MacColl Care Home 40 Category(ies) of Dementia - over 65 years of age (29), Learning registration, with number disability over 65 years of age (2), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (2), Old age, not falling within any other category (7) Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 2. The home is registered for a maximum of 40 service users to include: - up to 29 service users in the category of DE(E) (Dementia over 65 years of age) up to 7 service users in the category of OP (Older people not falling within any other category Two named service users in the category of MD(E) (Mental disorder, excluding learning disability or dementia over 65 years of age) may be accommodated within the overall number of registered places Two service users in the category of LD(E) (Learning disability over 65 years of age) may be accommodated within the overall number of registered place 7th March 2007 3. 4. Date of last inspection Brief Description of the Service: Kirklands is a modern, purpose built home situated in a residential area of Cockermouth. It is within walking distance of all the local amenities in the town centre. The home is operated by the Anchor Trust and managed by Mrs. Maureen MacColl. The home provides accommodation and care for up to forty older people, thirty of who may have dementia. The accommodation is on two floors, and is divided into four living units. Each unit has a lounge/dining room, with bedrooms, toilets and bathrooms close by. The home has a passenger lift and a range of other equipment to assist people in their day-to day-lives. There are garden areas that are provided with safe and secure seating areas. There is a car park to the front of the home. The maximum weekly fees for this home are currently £435.00 per week (March 2008). Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The assessment of this service took place over several days and included a visit to the service. Surveys were sent out to people who live or work at the home; some of the relatives of people that live at the home and to health and social care professionals. This helps to ensure that a wide variety of views and opinions are obtained about Kirklands. During our visit to the home we looked at some of the records kept at the home. We also spoke to some of the staff and some of the people that live at the home. One of our inspectors completed what is called a Short Observational Framework for Inspection (the SOFI). This is used to measure the well being of people with dementia who may find it difficult to tell us their opinions of the home. He observed residents and how they interacted with each other and with staff for a two-hour period during the morning and at lunchtime. This identified some good outcomes for people with dementia. What the service does well: What has improved since the last inspection? The manager has looked at the way in which the home is staffed. This has helped to make sure that there are enough staff available to support the needs of the people that live there. Another activities co-ordinator has been Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 6 appointed and this means that people living at the home have the opportunity to join in leisure and social events every day of the week if they wish. Some areas of the home have been redecorated and some new furnishings have been obtained. The way in which the housekeepers are employed has also been reviewed to help ensure that the home is always fresh and clean. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 7 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 Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 8 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 1 and 3. 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 this service. People using this service have their health and social care needs assessed prior to moving into the home. This helps to make sure that the home will be able to meet their needs and expectations appropriately. EVIDENCE: The home has produced a Statement of Purpose. This provides prospective residents with information about the services and facilities available at Kirklands. People thinking about moving into the home are able to visit prior to admission. The home offers a six week trial period. At the end of this period, a review is held to make sure that both parties are satisfied that the service provided is suitable. Some of the people participating in the inspection of this service say that they were given sufficient information about the home. This information helped them to decide whether Kirklands would be a suitable place to live. A sample of three care files was looked at during our visit to this home. They show that people have their health and social care needs assessed prior to Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 9 them coming to live at Kirklands. The home carries out assessments and where applicable, assessments are obtained from the person’s social worker. Where people are admitted to the home from hospital, transfer notes are also obtained so that the home has all the relevant information necessary to decide whether they are able to meet needs properly. The manager stated that the senior care workers at the home have received training to help ensure that assessments are undertaken properly. There is also a new pre-admission form in use, which helps to check that all relevant information is accurately obtained and recorded. Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. People using this service generally have a plan of how their health and social care needs will be met. There are gaps in the plans, which could compromise the health, safety and well being of people using this service. EVIDENCE: At the last inspection of this service, we asked the manager to ensure that everyone living at the home had up to date and detailed records of their health and social care needs. The manager has started to introduce new care records and plans. We looked at a selection of the new care records during our visit to the home. The care records demonstrate that people generally have access to health care professionals such as doctors, community nurses, opticians and chiropodists. There is a shortfall in access to dental care services but people living at the home are able to access emergency dental services when required. The manager is aware of this matter and recognises that it is an area that the home could improve upon. Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 11 The care plans are intended to contain lots of information about the individual needs and requirements of each person using this service. Records do not always demonstrate that people have been consulted and involved as much as possible in the development of their care plans. There are some gaps in the information recorded. For example some people have been identified as being prone to pressure sores and skin damage. Care plans do not have up to date information, including records and plans for the management of pressure care. However, there is pressure care equipment in place and the community nurse has been consulted. We also found that some people may have behaviour that can at times challenge. On checking the care plans there is not always a record of difficult behaviour or clear strategies to help staff respond in a consistent manner. Some staff confirmed that they are not always sure about how to respond. More attention should be given to ensuring that staff are aware of and able to safely manage the changing needs of people using this service. There is a procedure in place regarding the administration of medication. Medication is generally supplied in colour coded monitored dosage systems and records include a photograph of the resident. These measures help to minimise the risks of medication errors. Staff with the responsibility of administering medication have received training to help ensure that people are supported with their medication safely. One of these members of staff was spoken to: she had undertaken training both with the supplying pharmacy and a local college. A new supply of record sheets and medicines has recently been received at the home. The medicines are stored safely and appropriately with storage areas kept clean, tidy and well organised. There are suitable storage facilities for medication requiring cold storage and more secure storage for medicines that are liable to misuse. There were no people requiring this type of medication on the day of our visit nor were any people managing their own medicines. Care records include medication agreement forms. These show that the home is responsible for the administration and safekeeping of medicines. The forms are not fully completed. They have been signed by the manager only and not by the resident or a witness. This indicates that people may not have a proper assessment or have the choice of taking responsibility for their own medicines. We looked at a sample of medication records and medicines kept at the home. Two people had been prescribed medication to help relieve pain. The records show that this medicine has not been given as prescribed. When asked, the member of staff agreed that at least one of these people wouldn’t be able to tell them when they were in pain. She added that ‘staff would know by her body language’, but there are no details or instructions written in the care plan. Another person is prescribed medication to help prevent blood clots. The medication administration records had not been completed and there were some issues regarding blood tests. Although staff could provide a verbal update, this significant information had not been recorded in the medication records or the care file. These shortfalls place people using this service at risk from harm. Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 12 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 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. People using this service are generally able to make some decisions and choices about their lifestyle, although this is not always evident. EVIDENCE: The home has appointed three activities coordinators in addition to the core group of staff who generally support people with their everyday health and social care needs. The activities coordinators work over the seven days of the week ensuring there is a least one of them in the building each day and on some days two of them work together. They take a lead role in planning and facilitating a range of activities on a group basis and on a one to one basis. They offer a choice of sedentary and non-sedentary activities primarily in the home. There is also the use of a mini bus for day trips or outings. Activities provided give people both mental and physical stimulation and include things like chair exercises, craft sessions, manicures and tabletop activities. On the whole people seem to enjoy taking part in activities, which end up being an enjoyable social occasion. Some people prefer to opt out but their wishes are respected and alternatives offered to them. Other people choose to spend time in their own rooms, which again is a choice respected by staff. Staff have a good understanding about people’s individual needs and interests and are Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 13 able to engage them in conversation in a very natural and relaxed manner. Staff are respectful in their approach encouraging and supporting people to be independent. Organised events and religious festivals relative to the beliefs of the people in the home are celebrated. A spring fair was advertised on the notice board for residents and families. In addition an entertainer has been booked for a forthcoming concert in the home and a Bingo evening with a pie and pea supper is also planned. A record is maintained on people’s care plan files of what activities they have taken part in. The activities coordinators keep their own records to make sure a variety of activities are provided over the week. Each unit has a dining area where the meals and drinks are served from a hot trolley or from the adjoining kitchen. People have the choice to eat in their own room, at a dining table with others or in an easy chair. Residents are offered a choice of meal – two ‘sample’ plated meals are taken round so that people can make an informed choice about what food they want, which is good practice. The cook came out and served meals from the hot trolley. The cook talks to people and offers them choices and alternatives, which is a nice gesture, appreciated by the people who use this service. The meals are freshly prepared and the menus offer a good range of healthy nutritious food, with special diets and requests also catered for. Some of the practices observed are not always positive. One member of staff placed an apron on a resident without asking them if they wanted to wear one for their meal. Another member of staff started to help one person eat their meal, she left that person twice to do other tasks. She eventually did sit at the table and started to help two people at the same time. There was little interaction with the residents and staff mainly talked to each other. A member of staff came into the dining room to eat her lunch. She sat down in one of the easy chairs to eat her meal whilst talking to staff. This further reduced the interaction between staff and the people living at the home and does not demonstrate good practice. Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 14 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 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Kirklands are generally protected from mis-treatment and abuse by the policies, procedures and staff training that are in place. EVIDENCE: There is a comments/complaints procedure in place at the home and this is displayed on notice boards at the home. Some of the people participating in this inspection say that they are aware of the process and know who to raise their concerns with. They also think that any concerns they might raise will be dealt with properly. Other people who returned our questionnaires say that they are not aware of the complaints process but that they know who to address their complaints to if necessary. The adult protection process in place at the home has been updated. It includes the process for reporting concerns to internal managers, social services, the police and the Commission for Social Care Inspection. The procedures also address the staff recruitment process. This helps ensure that suitable people are employed after all the necessary checks have been made. Most staff have received some training in the subject of safeguarding vulnerable adults. The home also has a policy on physical interventions. Some care records and notes identify potential aggressive behaviour or language; clear plans for safe and suitable intervention are not always recorded. Some staff also feel that they would benefit from some training in helping people with challenging behaviour. These shortfalls potentially place both staff and people who use this service at risk from harm. Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 15 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 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a warm, safe and comfortable environment for the people that live there. EVIDENCE: The home is laid out in four units each with a lounge/dining area and shared kitchenette. Many areas of the home have been redecorated using colour schemes advised by the organisation’s dementia care specialist. The signs in use at the home showing people where fire exits, toilets and bathrooms are located have started to be replaced but this piece of work is not yet completed. The communal areas are furnished to a good standard and are clean and tidy. People living and visiting the home say that it is usually clean and fresh. Communal bathrooms and toilets are clean, tidy and equipped with suitable hand washing facilities and protective clothing for staff. These measures help to reduce the risk of cross infection. Bathrooms are fitted with a variety of aids and adaptations to help people access these facilities safely. Some of the Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 16 private bedrooms (flats) of people living at the home were looked at. All rooms are en-suite. The rooms have been personalised with their own items of furniture, ornaments and pictures to help make them more familiar and homely. On the day of the visit the home was warm and cosy and provided a comfortable environment for the people that live there. It was filled with spring flowers and most of the corridors have been decorated with pictures. One corridor in particular focuses on the Lake District and there are various items of interest, including pictures of local beauty spots on display. The home is equipped with hand rails and adaptations throughout to help maintain and encourage independence. There are call bells in each private room and in all communal areas so that people can call for assistance if necessary. Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 17 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 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using this service receive care and support from staff that are generally recruited and trained appropriately. EVIDENCE: The staffing ratios in the home have been reviewed to help make sure that there are sufficient numbers of staff to meet the needs of the people that live in the home. The daily staff compliment includes care staff, activities coordinators, a senior carer and a member of the management team. Two housekeepers are also employed to cover the domestic duties at the home. The home has a low turnover of staff and on the whole has a stable and experienced staff team. This means that people using this service generally have consistent care and support from staff. Based on feedback from surveys sent out as part of this inspection and our own observations and discussions during the day, people are receiving a good level of care and support. Staff say that they “work well as a team” and work closely with people and their families “to ensure they get the best possible care”. Over half of the staff team have achieved National Vocational Qualifications (NVQ) in care at either level 2 or 3. Sound recruitment policies and procedures are in place with all the necessary checks and references completed in a timely manner. Each member of staff has a personnel file, which contained all relevant information required by legislation. Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 18 Training records were examined and the manager keeps a record of the training received by each member of staff. The records do not include the duration of the training courses and this makes it difficult to assess if people are receiving the required amount of training recommended. The staff training and development plan was not seen during this visit. A training plan helps to identify any shortfalls in staff training. It also helps ensure that all staff are receiving appropriate training and refresher courses, therefore maintaining their skills and knowledge and following current good practice. We met and spoke to a number of staff during our visit to the home. They had a good knowledge and understanding of the people in their care and are ‘committed’ to their role. Visitors who we met during the day confirmed that staff are “kind and caring and always make you feel welcome”. We also observed staff working with some of the people that live at the home. In general they treated people with respect, dignity and were courteous and polite to them. There were some areas of poor practice identified, particularly in relation to manual handling techniques and helping people at mealtimes. These matters were discussed with the deputy manager during our visit to the home. Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 19 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 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An experienced and qualified management team runs the home. This means that the home is generally run in the best interests of the people that live there. EVIDENCE: The home is managed by experienced and qualified person. The manager is supported in her role by a deputy manager and a team of supervisory staff. The home also employs an administrator to help with the day to day running of the office. At our last inspection of this home we asked the manager to make improvements to some aspects of the home. These included improvements to some record keeping and staffing, including staff supervision. Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 20 The manager has started to address our requests and evidence was seen to confirm that improvements have been made in some aspects of the service. We examined staff supervision records and found that three people who had been employed since the last inspection did not have any record of supervision. On examining other files of longer serving staff the supervision records were also not up to date. We spoke to some of the staff. They said they “felt well supported by the management team and team leaders”. This was confirmed by the deputy manager who said that supervision is undertaken; “its on an informal basis and done verbally on the job”. She is aware of the importance of staff supervision and understands that it should be a more formal process. The manager ensures that the home is maintained to a reasonable standard and is generally a safe place for people to live. Electrical safety checks, gas appliances and central heating systems are serviced and checked regularly. Staff have received training in fire prevention and awareness. Each person living at the home has an a plan in their care records showing the support/assistance they would need if the home were to be evacuated in an emergency. There are risk assessments in place. They contain written instructions and diagrams to help alert staff to the level and type of risk. There are some shortfalls in the risk assessment process and the manager needs to carry out further work to ensure that all aspects of safety and risk are properly considered, recorded and updated within the specified timescales. This is particularly relevant where there are people who may demonstrate behaviour that challenges or where there are risks to the control of infection. There are also some shortfalls in assessing and recording the risks associated with limited mobility and the care of pressure areas. There is a quality assurance process in place at the home. Satisfaction surveys are in progress but not yet completed. A copy of the last organisational satisfaction survey (2006) is included in the home’s Statement of Purpose. Records in relation to the personal finances of people using this service are held by the home. The records are stored securely and clearly record money being placed into accounts and withdrawals. There balance is recorded together with receipts and signatures to help ensure security. Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 21 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15, 17 Requirement Care plan recordings must be more detailed when specialist needs are identified. Management plans must be developed to guide staff and ensure a consistent approach. This will help ensure that all aspects of the person’s needs are met appropriately. (Previous timescale of 30/04/07 not met). All staff working at the home must receive formal supervision at least six times a year. (Previous timescale of 30/04/07 not met). Timescale for action 30/04/08 2. OP36 18 30/04/08 3. OP38 13 30/04/08 Risk assessments must be carried out for all safe working practice topics. Significant findings and detailed instructions regarding the management of risks must be recorded. Risk assessments must be kept under regular review and be signed and dated. (Previous timescale of 30/04/07 not met). Kirklands DS0000022641.V356196.R01.S.doc Version 5.2 Page 23 4. OP9 13 Medication must be administered as the doctor prescribed and intended. 31/03/08 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 OP14 Good Practice Recommendations People who use this service should be encouraged and supported to make decisions over their own lives whenever possible, and be included in such decisions at all times. People using this service should be able to eat their meals in pleasant and congenial surroundings. Where staff assist people to eat their meals, this should be done in a sensitive and discreet manner. The duration of training courses should be recorded so that people receive the required level of training each year. 2. OP15 3. 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