Inspection on 07/03/07 for Kirklands

This inspection was carried out on 7th March 2007.

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 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

Kirklands 04/06/09

Kirklands 25/02/09

Kirklands 04/03/08

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 10:30 7 March 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kirklands DS0000022641.V314758.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.V314758.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 Anchor Trust Mrs Maureen MacColl Care Home 40 Category(ies) of Dementia - over 65 years of age (30), 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 (1), Old age, not falling within any other category (7) Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 40 service users to include: - up to 30 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 One named service user 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 23rd March 2006 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 £422.00 per week (March 2007). Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The assessment of this service included an unannounced visit to the home, discussions with the manager and staff as well as meeting and talking to some of the residents. Comments about this home and the service were received from residents, their friends and relatives as well as healthcare professionals. During this visit all the key standards of the National Minimum Standards were assessed. The registered manager had completed a pre-inspection questionnaire prior to this visit. This assisted in verifying information throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: A number of people who took part in this inspection raised concerns about the number of care staff on duty. Although care needs are usually met, they felt that there is not always a sufficient number of staff on duty to meet their leisure and social needs appropriately. The manager needs to look at the care Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 6 and social needs of people living at the home to ensure that there is always sufficient numbers of staff on duty. As part of this process, individual care plans would benefit from a review and update to ensure that all aspects of each resident’s daily living needs are considered and met appropriately. Some staff at the home have not been kept up to date with essential aspects of health and safety training and this matter also needs to be looked at by the manager. 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.V314758.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.V314758.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): 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have their personal care needs assessed prior to moving into the care home. EVIDENCE: The home has a Statement of Purpose that has recently been reviewed and updated. This information helps service users and their relatives to decide whether the home will be able to meet their needs and expectations. Samples of service user files were looked at during this visit. Records indicate that care needs assessments are obtained by the manager at the home prior to the admission of service users. Assessments are obtained from social services and/or hospitals as appropriate. This helps the manager to ensure that the home will be able to meet the needs of the people moving into the home. Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 9 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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of people living in this home are set out in a plan of care, which is generally reviewed and kept up to date. EVIDENCE: Each service user has a care plan, which provides care staff with some details of the support that each individual requires. Care plans are generally reviewed each month and include elements of risk assessment and nutritional assessment. Important information about the needs and wishes of service users is not always recorded in the appropriate place. This may mean that service users are put at risk or may not have their needs met in the most appropriate way. Mobility plans and assessments are not consistently signed and dated making it difficult to assess whether they are updated and reviewed regularly. Additionally there are no clear instructions recorded to help staff to deal with special care requirements appropriately. Records indicate that service users have access to their doctor, district nurses, chiropodists, community mental health nurses and are assisted to attend hospital appointments, dental appointments and opticians. Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 10 The home has policies and procedures relating to the administration of medication. The home’s own policy is reviewed and updated annually. Staff responsible for the administration of medication have received training to help ensure that this task is undertaken safely. Some of the medication records were looked at during this visit and were generally accurately completed. A photograph of each service user is kept with their medication record to assist with correct identification. The home has a designated fridge for the storage of medication requiring cold storage. This was locked on the day of the visit and daily temperatures are monitored and recorded. There was a considerable amount of one medicine kept in the controlled drugs cabinet. This medicine had not been administered for some time and the manager should ensure that this medicine is returned to the pharmacy. Service users are generally treated with respect and staff generally recognise the importance of maintaining the privacy and dignity of the people living at the home. Where staff required the help of a second person to assist with someone’s personal care, this was seen to be done in a sensitive and private manner. There was one incident observed where a service user needed to use the toilet and a member of staff was heard shouting down the corridor. There are details of service user’s bathing routines kept in the communal bathrooms. The manager should review this practice to ensure that the privacy and dignity of people living in this home is not compromised. Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 11 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 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are able to maintain contact with their families and friends, but they may not always have access to activities that meet their expectations and provide interesting and varied stimulation. EVIDENCE: The home employs two people who are responsible for arranging activities in the home. They are said to organise games, quizzes, arts and crafts and carry out one to one activities with individual service users. On the day of the visit there was some singing going on for a short period in the morning and the afternoon was taken up watching a video. Around lunchtime, staff were sat chatting to service users whilst waiting for lunch to arrive. On the day of the visit there appeared to be little stimulation and activities going on. The hairdresser was at the home and many of the ladies had their hair done. In one of the lounges the TV was on in one corner and the radio/music in the other. It was difficult for service users to hear and concentrate on the programmes. Some of the service users spoken to indicate that activities (Quizzes, bingo and other games) do take place, but this usually depends on the numbers of staff available and whether they are busy or not. Another service user participating in the inspection indicated that they would like to be taken out of the home from time to time. Comments from relatives also indicate that activities are limited and included the following observation; Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 12 ‘staff are lovely but I would like to see more interaction with the residents, not just at meal times.’ There are some arrangements in place to help ensure the safety of service users who may be able to go out from the home unaccompanied. Daily records looked at show that service users go out with family or friends and also attend church. The home welcomes visitors to the home and service users are able to see their visitors in private if they wish. Visitors are offered tea and biscuits when they visit and one person joins their relative for lunch on Sunday. Comments received from a health care professional indicated that the home had ‘helped to prevent hospitalisation and helped the service user to regain independence and a quality of life, which prior to residence at Kirklands would have been difficult to contemplate.’ The serving of the midday meal was observed. One service user had helped to fold the napkins whilst having a chat to a member of staff. The meal served corresponded to the meal on the menu and a vegetarian option was offered. Two people didn’t want anything that was on the menu and chose to have something else. This was prepared and served to them. Where soft diets were required, these were served in an attractive and appealing manner. Staff helped some service users with their meal. They sat at the table with them and helped in a sensitive manner. Discussions were taking place at the table and this appeared to be a pleasant activity for all involved. Staff checked that residents had enough to eat and offered more if required. There was a choice of puddings, including fresh fruit. The cooks are aware of people requiring special diets, for example diabetic, vegetarian and soft diet. Residents spoken to indicated that there was sufficient food in their opinion and that is was very good. Some residents are able to make themselves drinks and breakfast in one of the smaller kitchen areas. Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 13 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home are confident that their concerns will be listened to and acted upon appropriately. EVIDENCE: There is a complaint procedure in place at the home. A copy is available on the notice board at the entrance to the home. People coming to live at the home are provided with an information pack, which tells them about the home and includes the complaint process. These packs are sometimes given to family members instead. However, several relatives indicate that they are not aware of the complaint process in place at the home. People participating in the inspection indicate that they know who to complain to if they are not happy. They are confident that the staff will listen and take their concerns seriously. The home has not received any complaints recently. The home has a copy of the local authority’s safeguarding adults protocols. There are also organisational policies and procedures to help ensure the safety of people living in this home, including; abuse, risk management and restraint, working with violence and aggression and whistle blowing. There is a local procedure outlining the initial action staff should take should they suspect or receive an allegation of adult abuse. Staff are provided with a copy of the organisations Rights and Responsibilities booklet at their induction. This covers subjects such as adult abuse and working with violence and aggression. Staff training records indicate that staff undertake training in the protection of vulnerable adults, working with people who may have difficult behaviour and the safe handling of medication. Where resident’s care plans identify potential issues regarding physical or verbal aggression, clear plans for safe intervention Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 14 have not been recorded. This may mean that service users and staff are placed at risk from harm. Kirklands DS0000022641.V314758.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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is well maintained, clean and pleasant. EVIDENCE: Some of the rooms of people living in the home were looked at during the visit. They are clean, bright and there are en-suite toilet and sinks in the rooms. Service users are able to bring their own possessions into the home in order to personalise their rooms The doors to the individual service users rooms have letterboxes and locks. Keys are available to service users on request and subject to an assessment. The home has recently had a new fire alarm system fitted and new double glazed windows and doors. The home is now awaiting redecoration and this should take place in the next month or so. There are communal bath and shower rooms throughout the home and these are fitted with specialised baths and equipment to help service users maintain their independence and their personal hygiene. Throughout the home there are paper towels, soap dispensers and protective clothing available for staff. This helps to reduce the risk of cross infection. The home does have some problems with regard to the storage of equipment and Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 16 one bathroom in particular was used as a storage area for wheelchairs and hoists when not in use. There is a large and well equipped laundry at the home. The laundry is also due to be redecorated in the near future. The laundry is situated down the corridor from the main kitchen. On the day of the visit the kitchen and food storeroom doors were wedged open. Laundry is taken along this corridor and the doors should be kept closed to help minimise any risk of contamination. There are communal lounge areas and dining areas at the home. These are furnished with comfortable chairs, televisions and radios. Fire fighting equipment is available throughout the home and has been checked on a regular basis. There is a passenger lift at the home to help service users access all areas of the home. There are hand rails throughout the home and this also assists service users with their mobility. Outside there is a parking area and residents have access to a pleasant garden and patio area in the summer. The home has developed a fire risk assessment and the fire office has recently visited the home to update information. Kirklands DS0000022641.V314758.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): 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. Service users may not always be supported by sufficient numbers of staff to meet their needs. EVIDENCE: A sample of four staff files were looked at including recently recruited staff and staff working dayshift and nightshift. The records show that staff at the home are recruited in a safe manner. Application forms are completed and Criminal Record Bureau checks (CRB) and Protection of Vulnerable Adults list (POVA) are undertaken. Staff do not commence work until the results of these checks are known. Staff complete health questionnaires and attend for interviews as part of the recruitment process. Training records indicate that staff undertake induction training including shadowing shifts. Other training includes National Vocational Qualifications (NVQ), dementia care, medication, health and safety, infection control, manual handling, first aid, food hygiene and fire safety. Some of this training is not always kept up to date and undertaken as frequently as it should. This was particularly evident in the case of the night workers files looked at. There are training courses organised for the near future including – personal development training, fire, dementia and adult protection. Although managers and staff indicated that some staff supervision is undertaken, there are no recent records available to confirm that this is undertaken as frequently as it should. Several members of staff were spoken to on the day of the visit. They indicated that they felt the staffing levels are sufficient to help them meet the needs of the people living at the home. They also indicated that they are Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 18 supervised. Staff feel that they are provided with sufficient training to help them do their job properly. Staff have access to service user care plans and are able to write information in care diaries. This helps to ensure that staff at the home are fully aware of the needs of people living at Kirklands. The home operates a key worker system and staff are responsible for the care of a certain group of residents. This helps to ensure continuity and consistency of care for people living at the home. Some concerns regarding staffing levels at the home have been raised during the inspection of this service. Comments made include; ‘in general I am very pleased with the attitude of the staff and the care they take over my mother. The staff are very caring overall but there are not enough staff on duty’ and ‘there are sufficient staff in terms of meeting care requirements but perhaps not sufficient to provide more personalised therapeutic or diversionary/social activities.’ Service users returning questionnaires indicate that ‘staff are sometimes or usually available’ and some service users say that they ‘would like to be taken out from time to time.’ Staffing levels were discussed with the manager. The manager must review the staffing levels in conjunction with the assessed needs of people living at the home to ensure that there are sufficient numbers of staff on duty at all times to meet the personal care, social, cultural and recreational needs of the people living at the home. Kirklands DS0000022641.V314758.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): 31, 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. The home does not always follow health and safety procedures and guidelines. This potentially leaves service users and staff at risk from harm or injury. EVIDENCE: A qualified and experienced manager runs the home. A deputy and senior carers assist her in her duties. The home has a development plan for quality assurance but this has not been reviewed since January 2004. The quality monitoring systems used by the home were not looked at during this visit. The arrangements at the home for ensuring the security of personal money held on behalf of residents were looked at. Records of transactions, money coming in and out, receipts for shopping and balances are kept and signed for. Hand written and computerised records are kept. There are arrangements in place for the safe keeping of resident’s personal money. This was said to be in line with policies and procedures. Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 20 The lift and handling equipment such as hoists are checked and information indicates that the central heating system has also been serviced. The home has a fire risk assessment and fire safety plan. Emergency lighting and fire detection systems are tested and serviced at regular intervals. Fire drills are carried out both during the day and night and staff are provided with some fire training. Staff do not always attend this training as frequently as they should and the manager must ensure that this is attended to. A new fire alarm system has recently been installed at the home. Managers and staff indicate that some staff supervision is undertaken; there are no recent records available to confirm that this is undertaken as frequently as it should be. There are some staff at the home that have undertaken first aid training, infection control training and health and safety training. Records indicate that manual handling training is carried out but that some staff need refresher training to update their knowledge. There are risk assessments in place but these do not consistently include sufficient and relevant information to ensure that risks are minimised as far as possible. These documents are not always signed and dated, which causes difficulties in assessing whether they are kept up to date and reviewed. A sticker system is in place. Pictorial information is included on risk assessments, which helps to alert staff to some risks. The manager ensures that when residents are admitted to hospital or die, the Commission for Social Care (CSCI) inspection is notified as required. However, the accident book at the home shows that various residents have had an accident or fall. These matters have not been reported and the manager must ensure that CSCI is notified of all event and matters that affect the well being or safety of service users and the life of the home. Kirklands DS0000022641.V314758.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 2 2 X 2 Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 The registered person must ensure that each service user has an up to date care plan, which sets out in detail the action which needs to be taken by care staff to ensure that all aspects of the service user’s needs are met. The registered person must ensure that the care home is conducted in a manner which respects the privacy and dignity of service users, at all times. The registered person must ensure that intervention is only used as a last resort, in accordance with Department of Health guidance and protects the best interests of the service user. Interventions must be the minimum necessary, be consistent with safety and be fully documented within the service users plan of care. The registered person must ensure that the Commission is notified of any event, which adversely affects the well-being or safety of the service user. DS0000022641.V314758.R01.S.doc Timescale for action 30/04/07 2. OP10 12(4) 14/04/07 3. OP18 12(1) 13(6)(7) (8) 30/04/07 4. OP18 37 14/04/07 Kirklands Version 5.2 Page 23 5. OP27 12 18 6. OP30 18(1) 7. OP36 18(2) 8. OP38 13 The registered person must ensure that staffing numbers and skill mix are appropriate to the assessed needs of the service users, the size, layout and purpose of the home at all times. The registered person must ensure that at all times suitably qualified and competent staff are working at the care home. Staff must receive appropriate training and updates to ensure the health and welfare of service users is met at all times. This includes but is not limited to ensuring staff are up to date with fire training, manual handling training and health and safety matters. The registered person must ensure that persons working at the home are appropriately supervised. The registered person must ensure that risk assessments are carried out for all safe working practice topics and that significant findings of the risk assessment are recorded. Risk assessments must be kept under regular review and be signed and dated. 30/04/07 01/06/07 30/04/07 30/04/07 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 OP9 Good Practice Recommendations Medication that is not currently in use should be disposed of appropriately. This is particularly important in the case of ‘controlled drugs’. Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 24 2 OP12 It is recommended that the registered person undertakes further work to ensure that service users have opportunities to exercise their choice in relation to leisure, social and cultural activities and interests It is recommended that the registered person review the arrangements in place to enable service users to watch the television or listen to music without causing distraction to each other. 3 OP12 Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 Kirklands DS0000022641.V314758.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!