Inspection on 11/09/06 for Kirkstall Court Care Home

This inspection was carried out on 11th September 2006.

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

The inspector 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

Kirkstall Court Care Home 09/02/09

Kirkstall Court Care Home 05/03/08

Kirkstall Court Care Home 04/09/07

Kirkstall Court Care Home 02/11/05

Kirkstall Court Care Home 10/05/05

Kirkstall Court Care Home 11/11/04

Kirkstall Court Care Home 22/04/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Kirkstall Court Care Home 119-129 Vesper Road Leeds Yorkshire LS5 3LJ Lead Inspector Catherine Paling Key Unannounced Inspection 11th September 2006 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 Kirkstall Court Care Home DS0000001350.V308844.R02.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. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kirkstall Court Care Home Address 119-129 Vesper Road Leeds Yorkshire LS5 3LJ 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) 0113 2591111 0113 2257444 Dukeries Healthcare Limited Care Home 38 Category(ies) of Dementia (8), Learning disability over 65 years registration, with number of age (1), Old age, not falling within any other of places category (30), Physical disability (1) Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The place for LD(E) is specifically for a named service user. The place for PD is specifically for the service user named in connection with the variation application dated 25.6.4 2nd November 2005 Date of last inspection Brief Description of the Service: Kirkstall Court is a purpose built home, dating from 1991. The current providers have been registered since June 2000. The home provides personal care with nursing for up to 30 service users, both men and women, over 65 and very much serves its local community. In addition there are 8 places for the rehabilitation for under 65s with alcohol related dementia. Service user accommodation is provided over three floors with single rooms, all of which have en-suite facilities. There are two passenger lifts, one of which goes to all floors with the second going to the first floor. The home is on the main bus route into Leeds city centre, four miles away. It is also close to local shops and post office. The local pub is a short car journey away, close to Kirkstall Abbey and museum. There are seating areas outside the home, which are accessible to service users by means of a ramp. Information about the home and services provided are available in the form of a statement of purpose and service user guide for the elderly unit and for the dementia care unit, which is known as Champion Crescent. The current scale of charges range from a minimum of £420 on the elderly care unit and from £745 for Champion Crescent. This information was included in the pre-inspection information provided as part of the inspection process. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. All regulated services will have at least one key inspection between 1st April 2006 and 1st July 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people using it. All of the core National Minimum Standards are assessed and this forms the evidence of the outcomes experienced by residents. On occasions it may be necessary to carry out additional site visits, some visits may focus on a specific area and are known as random inspections. The visit took place on 11th September and 19 September 2006 and was unannounced. One inspector was at the home for a total of 11 hours. The manager was at the home on the second day of the visit. Telephone contact was made with the operations manager following the first day to provide some initial feedback. Full feedback was provided to the manager on completion of the inspection. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the residents and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at the number of reported incidents and accidents and complaints. This information was used to plan the inspection visit. A number of documents were inspected during the visit; some areas of the home were seen, such as bedrooms and communal areas. The inspector also spent a good proportion of their time talking to residents, staff and visitors. Residents who were unable to comment on their experiences were observed. The home was asked to complete a pre-inspection questionnaire (PIQ) to provide additional information about the home. This was given to the inspector on the second day. Comment cards were given to residents and relatives and a number have been returned. A comment card was also left with the manager to comment on how the staff felt the inspection process had been conducted. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The information now held within the care files needs to be reviewed to make sure that when staff refer to the records they have easy access to the information they need to properly care for the residents. There should be evidence within the file that residents and/or their relatives have been involved in the development of the care plans. The provision of food was not good and must be reviewed with the involvement of the residents and relatives to make sure that all residents receive a varied and nutritious diet and sufficient fluids. Although there appear to be enough staff on duty some residents and relatives felt that there were not enough. The manager needs to review the deployment of staff. The provision of activities and stimulation for residents needs to be reviewed as some residents were bored. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 7 The manager must make his application to the CSCI. Now the new unit has opened he needs to make sure that the elderly care unit is running as it should so that these residents no longer feel overlooked as they have done in recent months. Further details on the inspection can be found in the body of the report. Requirements made as a result of this inspection appear at the end of the report. 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. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. (Standard 6 does not apply to this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have sufficient information to make and informed choice about the home. All residents can be sure their needs will be met as they have their needs fully assessed prior to admission. EVIDENCE: An up to date Statement of purpose and service user guide is available together with previous inspection reports in the entrance area near the signing in book. The service provision has changed recently at the home and there is a small 8 bedded unit for the under 65s with alcohol related dementia. This unit has its own statement of purpose and service user guide. All residents have their needs fully assessed before they are admitted to the home. The format used makes sure that there is a good level of detail about Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 10 social and care needs as well as any necessary specialist equipment. The form details who did the assessment, when and where it was carried out; how long was spent with the resident as well as who contributed. There was evidence that residents are encouraged to and do visit the home wherever possible prior to admission. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. 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. Overall the healthcare needs of residents are met but the difficulty in accessing the relevant information within records could provide the opportunity for care needs to be overlooked. Residents are treated with respect and their privacy is respected. EVIDENCE: A sample of four individual residents’ files was looked at and included one from the new unit. The format of the records has changed since the last inspection and care plans and risk assessments are in place for all residents. The records appear to be a very comprehensive document but are not ‘user friendly’ as it is difficult to access the specific individual detail about care needs. There are a large number of risk assessments in individual files in addition to the ones which are required such as for nutrition, manual handling and for falls. One resident had an additional eight risk assessments that covered Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 12 areas that should be addressed within the home’s policies and procedures. For example, the identified risk ‘of a lack of privacy to the service user through staff enabling access to bedroom areas with over-riding key’. Proposed action is for staff to knock on doors and get permission to enter. Another example refers to a risk of ‘inappropriate use of medication’. Respecting residents’ privacy and safe medication practices are fundamental and staff should be working to clear and robust policies and procedures, which should reflect such basic expectations of staff. These areas of care are relevant to all residents and to be included in individual files has the result of making it hard to access the specific detail and information about care needs. Some of the care plans did include some good specific detail. For example, detail of the type of incontinence pad to be used during the day and at night. However there was an absence of the recognition of the strengths of residents, what abilities are to be encouraged. There was not always evidence of the involvement of residents and/or their relatives in the development of the plans even in the case of residents who were capable of contributing to them. Evaluation does not provide a clear overview of the effectiveness of the plan for the previous month. There is a ‘daily routine’ sheet which provides a useful overview of how the resident spends their day although it could be made more useful with more specific information – this was not seen in every file. For example, the relative of one resident takes them out regularly but when and what time was not detailed on this record. Residents psychological needs were not being addressed and although attempts had been made to approach end of life decisions this needs development. It was evident from the records that staff did not understand the specialist needs of residents with dementia. There were records of the input from other healthcare professionals such as the general practitioner, tissue viability nurse and the physiotherapist. The standard of recording on the unit was high and demonstrated person centred care with a detailed record of needs and progress. The observations about the records were shared with the company after the first day of the inspection. The manager had devised an action plan by the second day and had already recognised the need to support staff in the development of person centred records. The medication room has been re-sited as part of the refurbishment of the home. The new room provides a much more suitable area for storage and management of the medicines. Regular internal audit is carried out for the administration of medication. Observed administration procedures were satisfactory. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 13 Staff were observed to respect the privacy and dignity of residents. Residents also feel that staff respect their privacy and dignity. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ choices are respected and contact with family and friends is encouraged. Some residents are bored and the provision of activities and stimulation for residents needs to given priority. The provision of diet and fluids is not adequate and needs to be reviewed to make sure that residents are provided with a nutritious and varied diet. EVIDENCE: Visitors are welcomed at the home at any time and several were in the home during the inspection. Residents are encouraged to maintain contact with their family and friends and some go out regularly to spend time with their families or to local clubs and to make use of the local amenities. There is currently no activities organiser although the post has been advertised and prospective candidates interviewed. In the meantime there is little for residents to do and some are bored. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 15 Several relatives and residents spoken with made comments about the poor quality of the food. For example, that the main meals are of ‘poor standard and look very unappetising’ and that ‘the food leaves a lot to be desired served cold and inedible’. The lunchtime meal looked unattractive and many residents did not eat it. Meals were left in front of residents and by the time they got the assistance they needed the food was cold. Meals were taken uncovered to resident’s rooms. Overall the mealtime was not well managed and the food was not good. Kitchenette areas have been provided in all communal lounge areas with the intention of ensuring that hot and cold drinks and snacks are available all day for residents and their relatives. However, during the course of the day drinks were not freely available and nourishing snacks were not provided midmorning or mid-afternoon. One resident was seen to empty their cup and then lick the outside suggesting that they were still thirsty. Staff did not notice and missed an opportunity to maintain a good fluid intake for this resident. The teatime meal was unimaginative. Sandwiches are served regularly for this meal and records of a meeting said that residents requested pickles to be served but none were seen. Care staff said that even though the kitchenette areas had been developed there were insufficient cups available and fridges had not been provided. This meant that staff still had to go back and forth to the kitchen to get drinks for residents. Feedback was provided to the company following the first day of the visit. On the day when the visit was completed the manager had already taken some action and had a plan in place to address the shortfalls identified in the provision of diet and fluids to the residents. For example, meetings had been arranged with staff and the relatives and residents; he had met with the cook and additional training was to be offered and fridges had been ordered for the kitchenette areas. The manager had also arranged for a visit from the community dietician for advice about food provision at the home. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with appropriately. Overall, service users are protected from abuse with the staff aware of adult protection. EVIDENCE: The complaints procedure was displayed in the entrance area near to the signing in book. There was also evidence that the procedure was made available to residents on admission to the home. There was a record of complaints and three have been received since the last inspection. There was good evidence of through investigation and input from company representatives. There was no clear conclusion as to whether the complaint had been upheld or not and the records would benefit from this addition. Staff were clear about adult protection and had no hesitation in sharing concerns with the manager. There was a whistle blowing procedure at the home, displayed in the entrance area. Further training is planned around adult protection for all staff. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. 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. The home has been refurbished to a good standard and provides a safe and comfortable environment for residents. Some practices create the opportunity for cross infection, potentially placing residents at risk. EVIDENCE: Over recent months there have been major changes at the home resulting in changes to the registration category. There is now an eight-bedded unit for the rehabilitation of those suffering with alcohol related dementia. This has resulted in a change to the communal lounge and dining facilities for the elderly residents. The upstairs lounge has been extended to provide lounge/dining facilities and now includes a kitchenette area; the main lounge downstairs also benefits from the addition of a kitchenette. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 18 The majority of the refurbishment is complete. The conservatory in the new unit is to be replaced; a patio area and access doors are to be provide of the main lounge in the elderly unit. The environment has been improved by the changes to date, although some of the elderly residents do miss access to the conservatory. The shower room on the top floor was being used for storage and there were COSHH products, for example pine disinfectant in an unlocked cupboard. Unbagged incontinence pads were seen in several areas and provide the opportunity for cross infection. The laundry door was open despite the notice that stated that the door should be shut when the laundry is unattended. Information included in the PIQ indicates that maintenance of equipment is carried out and is up to date. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. 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. The skill mix and numbers of staff are sufficient to meet the needs of the residents. The staff are being provided with the right level of training to make sure that they are competent to do their jobs and that the residents are safe. EVIDENCE: Duty rotas indicated that there are sufficient nursing and care staff to meet the needs of the residents. The care staff are supported by a team of ancillary staff. There is a separate staff team for the new unit and staff who work on that have received training. Comments from relatives are that there sometimes does not appear to be sufficient staff on duty and some residents said that they were sometimes kept waiting when they asked for assistance. The manager should review the staffing levels together with the dependency levels of residents as well as the current methods of the deployment of staff. The majority of the care staff team have a National Vocational Qualification in care to at least level 2 with several trained to level 3. Recruitment practices are robust and all the required checks are carried out prior to the start of employment at the home. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 20 The manager has commenced dementia awareness training for staff. This is to take the form of four sessions looking at aspects of dementia and including person centred care. The manager has extended the training to interested relatives and it will be repeated to make sure all the staff attend and any interested relatives have the opportunity to take advantage of the invitation. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is reasonably well organised and there is a commitment to involving the staff and residents in the running of the home. The interests of the residents are safeguarded at all times. EVIDENCE: The manager has been in post for several months but at the time of the inspection had yet to make application to the CSCI to be registered. He is an experienced nurse and is well qualified. Since staring as manager much of the manager’s time has been taken up with the development of the new unit. Some relatives and residents on the elderly unit said that they had felt overlooked during this time and said that they were ‘reserving judgement’ about his effectiveness as manager. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 22 However, the manager is making attempts to involve residents in the running of the home and one resident has already been involved in interviews for new care staff as well as an invitation to attend training sessions for information. He has already had meetings with relatives and residents since his arrival at the home and in the light of findings from the first day of the inspection a meeting was already planned to discuss the issues around food provision. The manager had also met with staff since the start of the inspection to discuss the concerns around nutrition. The notes of the previous staff meeting held 4th September 2006 were available and showed that discussion had taken place around care practice and training and development. There is a system of internal audit that includes monthly returns to head office. The manager has not yet established his own system of getting the returns submitted on time. There is support from the manager from head office and there are regular visits to the home from senior staff. Accident reports are kept and showed reasonable detail. It should be clear in the report if the account of the accident is what the resident has said. If the accident is unwitnessed the time the resident was last seen should be recorded. Some residents’ monies are handled at the home dealing in the main with individual’s payment for hairdressing and chiropody services. Clear records were kept but there was only one signature. Consideration should be given to invoicing residents for these services which would removed the need for this money to be kept for residents. Although it appeared that there are lockable facilities for residents to keep valuables in their rooms it appears that there are no keys available. Arrangements must be made for residents to keep valuables in lockable facilities in their rooms if they wish to. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 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 2 2 X X 2 X X 3 Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 24 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 Requirement The manager must make sure that the information about care needs is accessible to care staff to make sure care needs are not overlooked. There must be evidence that residents and/or their representatives are involved in the development of care plans. The provider must consult the service users about a programme of activities and provide opportunities for recreation and stimulation for the residents. A review must take place of the provision of food and drink to make sure that all residents receive suitable and nutritious food and an adequate fluid intake. The provider must make sure all staff have received appropriate training in relation to adult protection. The manager must make application to the CSCI without further delay to be registered as manager of the home. DS0000001350.V308844.R02.S.doc Timescale for action 15/01/07 2 OP12 16(2)(n) 15/01/07 3 OP15 16(2)(i) 27/11/06 4 OP18 13(6) 05/02/07 5 OP31 9 30/10/06 Kirkstall Court Care Home Version 5.2 Page 25 6 OP35 16(2)(l) Secure lockable facilities must be 06/11/06 provided for residents. 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 2 3 Refer to Standard OP27 OP33 OP35 Good Practice Recommendations The manager should review staff deployment to make sure that staff are being deployed effectively for the benefit of the residents. The outcome of audits carried out as part of the quality assurance programme should be shared with all interested parties. Consideration should be given to invoicing residents for hairdressing and chiropody to keep the holding of residents money at the home to a minimum. Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Kirkstall Court Care Home DS0000001350.V308844.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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