Inspection on 26/04/06 for Kirklands Care Home

This inspection was carried out on 26th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kirklands Care Home 09/05/07

Kirklands Care Home 18/01/06

Kirklands Care Home 01/08/05

Kirklands Care Home 07/03/05

Kirklands Care Home 04/05/04

Similar services:

London Road Neurological and Specialist Care Unit

Carlton Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Kirklands Care Home 2 Fairhaven Kirkby-in-Ashfield Nottinghamshire NG17 7FW Lead Inspector Richard Ramsden Unannounced Inspection 26th April 2006 09:15 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 Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Kirklands Care Home Address 2 Fairhaven Kirkby-in-Ashfield Nottinghamshire NG17 7FW 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) 01623 723936 01623 723946 Nottinghamshire County Council Mrs Virginia Bullock Care Home 29 Category(ies) of Dementia (14), Dementia - over 65 years of age registration, with number (14), Old age, not falling within any other of places category (29), Physical disability (5) Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Out of the total number of beds (29) there will be 14 beds for DE 55 and over and/or DE(E) Out of the total number of beds (29) 5 may be used for PD 55 and over Service Users shall be within category OP (29) Date of last inspection 18th January 2006 Brief Description of the Service: This is a Local Authority older persons care home offering 29 beds, with attached day centre facilities. The home is on two floors with vertical lift access to the first floor and all service users have single bedrooms. Grab rails and call alarms are sited around the home and there are assisted bathing facilities. The home is set within a secure enclosed garden and is sited in a residential area conveniently close to the town centre of Kirkby-in-Ashfield and close to public transport routes. At the time of this inspection the senior staff stated that the homes monthly accommodation charges for those residents who are self funding would be £1508 per calendar month. A copy of the most recent inspection report is available in the home. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector completed this unannounced visit over one-day it took approximately 8.5 hours. It included the inspection of care under the records, a discussion with the manager, the cook and two members of care staff. The inspector spoke with four residents and two visitors to the home. A partial tour of the building was also completed. Prior to completing this visit the inspector assessed the homes previous inspection reports and service history. What the service does well: The staff are ensuring that they can meet the assessed needs for prospective residents prior to their admission to the home. Individual care plans show that resident’s health care needs are being adequately met; the residents spoken with during the inspection confirmed this. Residents said that they were very satisfied with their bedrooms and confirmed that they could use them at any time. Two people said that they had been encouraged to personalise their rooms with small items of furniture, photographs and ornaments. One person said that she had chosen the wallpaper when her room was redecorated. (This is good practice). The manager is well qualified and experienced, she ensures that residents and staff can voice their opinions about the way in which the home is run. The residents, staff and visitors spoken with during the inspection said that the manager is very approachable and they believed they could discuss any issues or concerns with her. The residents and visitors described the staff as caring and considerate and said that they ensure that resident’s privacy and dignity is respected at all times. They said that although the staff worked very hard they always find time for a “laugh and a joke”. One visitor who spends time in home every day said that she hopes, she can find somewhere as “good” as Kirklands if she ever requires residential care. The registered person is working hard to ensure that at least 50 of the staff has an NVQ qualification. Staff commented that they received a considerable amount of training, which helps them to perform their duties. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 6 The home has a good Quality Assurance System, which seeks the views of the people who use the service. The manager in consultation with residents and staff produces annual development plans for the home. (This is good practice). What has improved since the last inspection? What they could do better: All residents care plans must be reviewed and where appropriate updated at least once each month, this will help to ensure that staff are always aware of what support and assistance each resident requires. Although there have been some improvements to the homes medication systems, the registered person must ensure that staff follow the homes medication administration policies and procedures. A more substantial lock must be provided to the laundry room door so that residents cannot gain access when there is no staff in situ. The laundry contains hazardous equipment and on occasions soiled or infected laundry and could present a health and safety risk to the residents. The registered person must keep a record of all complaints to provide an overview of the nature and frequency of complaints received. Staff must be aware of the procedures they should follow if residents ask to see their own personal records. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 7 The registered person must ensure that the door to the sluice room is kept locked as this room contains hazardous cleaning materials. The homes emergency call system must be checked and serviced on a regular basis. 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. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6. The registered person ensure that the home can meet the needs of prospective residents by obtaining full written assessments prior to their admission to the home. The home does not provide intermediate care. “Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service”. EVIDENCE: Of the three residents records, which were assessed as part of this inspection, two contained social work assessments, which had been obtained prior to the resident’s admission to the home. The manager stated that a preadmission assessment had been obtained for the third resident but that this had gone missing. She stated that she had attempted to obtain another copy that had been unsuccessful. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 10 The manager confirmed that residents are never a admitted to the home until a preadmission assessment has been obtained and staff are clear that they will be able to meet the residents assessed needs. The home was not accommodating any residents from minority communities at the time of this inspection. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Residents individual care plans appear to contain sufficient information to ensure that staff are aware of what support and assistance each resident requires. However the registered person must ensure that there is evidence that all care plans are being reviewed on a regular basis so that staff always have up-to-date information on the residents care needs. Residents health care needs are being met. Some improvements have been made to the way in which the homes medication system is managed however other areas are potentially putting the resident’s health and safety at risk. Residents are treated with respect and their rights to privacy are upheld. “Quality in this outcome area is poor. This judgment has been made using available evidence including a visit to the service”. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 12 EVIDENCE: Three residents care plans were viewed as part of this inspection, the care plans appeared to address the issues highlighted in the resident’s assessment process. Records showed that two of the residents care plans were being reviewed on a monthly basis. However there were no records to indicate that the third resident’s care plan had been updated since the last inspection. This resident requires considerable physical support and assistance from staff and it is therefore essential that their care plan is reviewed on a regular basis. The homes medication was stored securely at the time of this inspection. Photographs of each resident are now available with each individual medication administration record. The manager has introduced a system to ensure that staff record the temperature in the room where medication is stored. On some occasions the temperature was above 25°C and the manager had taken appropriate action to reduce the temperature. The manager had chosen to treat some night sedation as medication requiring special vigilance in its storage and administration. Staff had not followed the appropriate procedures when recording the receipt and disposal of medication. They had also failed to record that they had checked to confirm how much of the medication remained in the home. It was therefore impossible to check if any of the medication was missing. This is potentially putting residents health and safety at risk. All of the staff that administers medication have received appropriate training. It is therefore difficult to understand why they are not following the homes medication administration procedures. (The manager has confirmed that since the inspection she has consulted with the homes pharmacist about providing a safer system for the administration of medication). All of the resident spoken with during the inspection said that staff are always friendly and respectful and that they ensure that their privacy and dignity is maintained at all times. This was also confirmed by the relatives who were spoken with during the inspection. Both of the visitors stated that they visit their relatives every day and that staff are always kind and considerate. One of the visitors stated that if she ever needs residential care she hopes that she can find somewhere as good as Kirklands. The observed interaction between staff and residents was of a very good standard Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Residents are satisfied with the frequency and variety of activities and entertainment provided by the home. People are encouraged to maintain contact with friends and family. Where possible people are encouraged to make decisions about their individual lifestyles. However the registered person must ensure that staff are aware the procedure they must follow if people wish to have access to their personal records. The diet provided for the residents is varied, wholesome and nutritious. “Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service” Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 14 EVIDENCE: The manager stated that the programme of activities to be provided for residents is displayed in the home on a weekly basis. However this program could not be located at the time of inspection. The manager stated that sometimes residents remove the information from the notice board and said that she would discuss with the staff and residents if there were more appropriate ways of displaying this information. The programme of activities was redisplayed on the notice board during the inspection. All of the residents spoken with during the inspection stated that they are satisfied with the frequency and variety of activities and entertainment provided. The care plan is viewed as part of this inspection contained details of residents past and present interests. Residents and their relatives confirmed that visitors are made welcome at any time. Two visitors said that they visit their relatives every day and that they are always made to feel very welcome. One resident said that she can see visitors in her bedroom or in one of the communal areas if she wishes to see them in private but does not want use her bedroom. At the time of inspection the manager could not locate an Access to Records Policy, this was however located during the inspection and displayed in the reception hall. The staff and residents were unclear what procedure they would need to follow if the resident or their representatives wish to see a residents personal care records. It is important that residents and where appropriate their representatives can have access to their individual personal records in accordance with the Data Protection Act 1998. Staff must have an understanding of this procedure. The residents spoken with said that they are satisfied with the meals provided by the home. They confirmed that there is always a choice of meal and that if they do not want the food suggested on the menu an alternative will always be provided. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 15 One resident confirmed that she could have her meals in her bedroom if she chose to do so. The inspector witnessed a visitor having their tea with their relative during the inspection. Staff confirmed that relatives are welcome to stay for a meal in the home. (This is good practice). The refrigerator, freezer and food temperature records were checked and they had all been well maintained. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Residents and relatives believe that their complaints would be taken seriously and that appropriate action would be taken. However the staff are not keeping appropriate records of all informal complaints and consequently the home does not have an overview of the nature and frequency of complaints received. The registered person has taken appropriate action to protect residents from abuse. “Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. EVIDENCE: The home has a user-friendly complaints procedure, which is displayed in the main reception area. The homes complaints records show that no formal complaints had been received since 2002. However a visitor who was spoken with during the inspection said that she had complained in writing about the food provided on one occasion. The manager produced the letter and stated that she would have recorded the details when she had completed her investigation. She confirmed that ‘ informal ’ complaints would be recorded in the senior staff handover book. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 17 The manager was informed that there must be a record of all complaints, detailing the investigation and where appropriate any action taken. These records will provide an overview of the nature and frequency of complaints received. There has been one incident of abuse in the home in the last 12 months. The registered person has taken action to ensure that appropriate procedures were followed to ensure the safety and welfare of the residents. The home has an appropriate Whistle Blowing Procedure, which includes details of who people can contact to deal with issues if they do not feel it is appropriate to contact their line manager. (This is good practice). The staff spoken with during the inspection had a clear understanding of the Whistle Blowing Procedure. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. The premises are generally well maintained and comfortably furnished. However some requirements were made, following the last inspection, to improve health and safety, these have not all been fully implemented. At the time of inspection the home is clean and there were no offensive odours. “Quality in this outcome area is acceptable. This judgment has been made using available evidence including a visit to the service”. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 19 EVIDENCE: A partial tour of the premises was completed as part of this inspection. The residents said that the accommodation is comfortably furnished and acceptably decorated. The staff have completely redecorated the first floor corridor. (This is good practice). The residents spoken with during the inspection said that they are very satisfied with their bedrooms and confirmed that they had been encouraged to personalise them with small items of furniture photographs and ornaments. One person said that she had chosen the wallpaper when her room was redecorated. (This is good practice). Residents and visitors confirm that the home is always kept very clean and tidy. Since the last inspection window restrictors have been fitted to the new double glazed windows to ensure the safety of the residents and their personal belongings. At the last inspection and number of requirements were made, to improve health and safety within the home. These requirements have not been fully implemented. It was required that a lock be fitted to the laundry room door to ensure that vulnerable residents do not have access when there are no staff in situ. The manager stated that a small bolt has been fitted, but this does not ensure that all residents cannot gain access to the laundry room. She stated that she has requested that a keypad lock be fitted, but this work had not been completed within the agreed time scales. A light that was fitted at the top of the stairs in the main entrance to the home was potentially hazardous to anyone over 6 feet tall. The manager stated that a contractor had visited the home one 20/01/06 to rectify this problem but that they had been unable to complete the work. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 20 A ramp leading to the outside of the home was slippery and a health and safety audit completed in May 2005 had stated that the wood underneath the ramp needed to be checked. The manager said that the ramp has been checked and is considered safe. A non slip coating is to be applied to the ramp. During the tour of the premises it was noted that a sluice room door had been left open, this room contained cleaning products and residents health and safety was put at risk. The manager was informed that this door must always be kept locked when there is no staff in situ. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The rota provided for the week of this inspection showed that adequate staffing levels are being maintained. The homes recruitment policies and practices are supporting and protecting the residents. The home is able to demonstrate a commitment to staff training. “Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service”. EVIDENCE: The rota provided for the week of this inspection showed that sufficient staff are being provided to comply with previously agreed staffing levels. The manager was reminded that she must constantly assess the residents dependency levels to ensure that there are always enough staff to meet there are assessed needs. The residents spoken with during the inspection said that although the staff are always very busy they always find time for social interaction. Residents confirmed that their individual needs are always met. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 22 The personal records of the two most recently recruited members of staff were assessed as part of this visit; each set of records contained an application form and satisfactory Criminal Records Bureau check. Although there were no references on the staff files copies of the references have been forwarded to the inspector and these were satisfactory. Out of a total of 31 members of staff ten people have completed their NVQ level 2 or above. Eight more members of staff were completing their NVQ training at the time of this inspection. The registered person is working hard to ensure that at least 50 of the staff has an NVQ qualification. The staff spoken with during the inspection all confirmed that the home provides a high level of training and support. The staff records viewed during inspection showed that one of them had completed their induction training and the other person was completing it at the time of inspection. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. The registered manager is qualified, competent and experienced to run the home. The home is run in the best interests of the residents. Resident’s financial interests are safeguarded. Efforts are made to protect the health and safety of residents and staff. “Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service”. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 24 EVIDENCE: The registered manager has managed homes for older people since 2000. She has been the manager at Kirklands Care Home since 2001. She is a State Enrolled Nurse and has a Certificate in Social Services Care of the Elderly. She has completed the Registered Managers Award and has a Professional Certificate in Public Service Management. The residents, their relatives and other members of staff spoken with during this inspection all confirmed that the manager is very approachable and seeks their views about the day-to-day running of the home Quality monitoring systems are in place, which shows that residents and their representatives have been encouraged to express their views about the services, provided by the home. The inspector is able to view the local authority business plan as well as the homes own annual development plan which had been produced as part of the quality assurance system. (This is good practice). The records of some resident’s finances were checked and had been satisfactorily maintained. The environmental health officer visited Kirklands in July 2005 the report stated that this was an ‘ excellent’ visit with no recommendations or requirements. Records show that the fire officer has not visited the home since June 2003. The manager confirmed that there is no work outstanding from this visit. The homes Fire records were viewed and all had been satisfactorily maintained. The homes Legionella risk assessment was checked and appeared satisfactory. Water temperatures are being checked and recorded on a regular basis. The homes hoists and beds were serviced on the day of this inspection; records show that the lift was last serviced in October 2005. The inspector tested the call bell in one of the resident’s bedrooms this was not answered by staff. When staff checked the call bell, the plug had become slightly loose and while this was not detectable in the room it did mean that staff were not alerted by the pager system. When the inspector asked to see the call bell service contract he was informed that the home does not have a contractor to service the emergency call bell system. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement It is required that all care plans are reviewed at least once each month and that evidence is provided that residents and where appropriate their representatives have been involved in the review process. (This is outstanding from 06/03/06) It is required that: 1) The Registered person ensures the records of receipt & disposal of medication are accurately maintained. 2. That staff always follow the homes procedures in the administration of medication. It is required that: The light at the top of the stairs in the main entrance hall must be altered so that it does not present a Health & Safety risk. (This is outstanding from 06/03/06) It is required that: A lock must be fitted to the laundry room door. This room DS0000036318.V290305.R01.S.doc Timescale for action 29/05/06 2. OP9 13 26/04/06 3. OP19 23 29/05/06 4. OP19 23 29/05/06 Kirklands Care Home Version 5.1 Page 27 must be kept locked when there is no staff in situ. (This is outstanding from 06/03/06). The manager has had a bolt fitted as an interim measure. 5. OP19 23 It is required that the sluice 26/04/06 room door is kept locked at all times when there are no staff in situ. The provision of an automatic closure on this door would resolve the problem. It is required that the emergency 29/05/06 call system is checked and serviced on a regular basis. 6. OP38 23 (2) (c) 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 It is recommended that staff are made aware of the procedures they must follow if residents or their representatives wish to have access to their personal files. Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kirklands Care Home DS0000036318.V290305.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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