Inspection on 06/10/05 for Kirkstall Lodge

This inspection was carried out on 6th October 2005.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 20 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kirkstall Lodge 25/05/07

Kirkstall Lodge 21/11/06

Kirkstall Lodge 25/07/06

Kirkstall Lodge 23/04/05

Kirkstall Lodge 07/02/05

Kirkstall Lodge 08/09/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Kirkstall Lodge 56 Kirkstall Road Streatham London SW2 4HF Lead Inspector Mary Magee Unannounced Inspection 6th October 2005 10:00 Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 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 Lodge DS0000053104.V256481.R01.S.doc Version 5.0 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 Adults 18-65. 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 Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kirkstall Lodge Address 56 Kirkstall Road Streatham London SW2 4HF 01491 579 270 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) Kirkstall Lodge Limited Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd April 2005 Brief Description of the Service: Kirkstall Lodge is a care home for six adults with a learning disability. It is in a semi-detached house located in a residential street in Streatham, South West london. It is close to public transport routes, shops and leisure facilities. It is two storey and is unsuitable for people with very restricted mobility as the front access is via a number of steps. The garden to the rear is small and has a garden house. There are plans to convert this to a sensory room for service users. As the house is very closely linked to adjoining properties noise can be transmitted very easily, therefore there must be a consideration to this when offering new service users a place at the home. The home is owned and managed by Beacon Care, a private care provider with many other homes in London and the South East of England. Currently the home provides 24-hour care and support to four adults. Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took two consecutive half days. There are two vacancies at the home. All four-service users were present over the inspection period and met the inspector. The manager and two members of staff as well as the area operations manager also met with the inspector. A selection of records was viewed. These included a sample of files for service users and members of staff. A tour of the premises was conducted that included all the communal areas and three bedrooms. What the service does well: What has improved since the last inspection? Major changes have taken place to the staff team. Members of staff that were not of satisfactory standard are no longer employed at the home. A caring ethos is promoted at the home. The staff team demonstrate a real commitment to looking after service users in a way that respects their individuality. Support workers are more aware of what they need to do to meet service users’ needs. Interaction between service users and staff is more appropriate. Service users have more opportunity to lead fulfilling lifestyles and for personal development. The inappropriate placement of a service user identified at the previous inspection has been addressed. A review was undertaken by the local authority for the service user resulting in him relocating to a more suitable home. The home has responded positively to complaints received and put in place measures to reduce unnecessary inconvenience to people living locally. Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 123 The changes made to the staff team have resulted in a positive outcome for service users. Staff can effectively communicate with service users and deliver the appropriate service to meet their assessed needs. EVIDENCE: The manager confirmed that service users had received copies of the updated Statement of Purpose and the Service Users’ Guide. A copy of these, plus the most recent inspection report, was on display in the hallway. Each service user should have it explained by his/her named key worker what is contained in the service users’ guide before it is placed in their care file. There has been no new service users admitted since the last inspection. Improvements were seen in the quality of care delivered by staff. Interaction between service users and staff was positive and appropriate. There was evidence that staff were familiar with the needs of service users and that there were clear lines of communication. Staff members present displayed empathy for people with learning disabilities. At the previous inspection it was identified that not all members of staff had the necessary skills to meet the assessed needs of service users and in particular the needs of a service user inappropriately placed. The service user referred to has moved to a more suitable placement. There has been a change to management and staffing personnel. Staff that were Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 9 found not delivering care to satisfactory standards have been removed. Newly appointed staff spoken to appear enthusiastic and keen to learn new skills. Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6789 Support staff are aware of the care arrangements for service users but these have not been kept under review. Improvements are needed to the way service users are supported to take risks and lead as independent a lifestyle as possible. EVIDENCE: Members of staff spoken to demonstrated a good knowledge of individual service users’ support needs. These they knew from handovers and from working together as a team. Written records were however not up to acceptable standards. Requirements had been made at two previous inspections regarding the reviewing and updating of care plans. These had not been actioned. Service user care plans and risk assessments had not been reviewed and did not reflect changes to individual’s needs. Information recorded on some care files dated to a previous twelve-month period with no evidence that plans had been kept under review. For example a service user that experienced significant changes in her conditions these had not been reflected in her plan of care or her risk assessments. An Immediate Requirement was issued relating to the review of care plans and risk assessments. Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 11 On day two of the inspection the manager showed the inspector evidence of the work that she was undertaking and the progress so far that she had made in reviewing care plans and risk assessments for one service user. Confirmation was received in writing that all the care plans/risk assessments at the home had been reviewed and that they currently reflected individuals assessed care needs. Improvements were found in the recording of financial transactions within the home and the auditing of petty cash. However there was a lack of transparency in financial procedures adopted to support service users to manage their finances. Some service users had individual savings account books held at the home with other savings books held at head office. It was not possible to examine how service users received their personal allowances including DLA. Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 12 13 16 17 Services and support are provided that enable service users to maintain appropriate and fulfilling lifestyles both in and outside the home. EVIDENCE: There were significant improvements noted in the quality of life offered to service users and particularly relating to opportunities for personal development. All service users were absent from the home when the inspector arrived. Two were involved in the weekly shopping expedition and took responsibility for unloading the provisions from the van. Another service user was attending the day centre with a support worker accompanying. She returned at a later stage in the day. Activity programmes in place for service users ranged from college/day centre to trips to the parks. Some difficulty has been experienced by service users enrolling at local colleges as there has been too great of a demand for places. Those not attending education courses participate in active learning activities Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 13 at the home and at day centres. At weekends activity programmes are in place with adequate numbers of support staff available to enable this. Photographs were on display of recent holidays enjoyed by service users. Service users are supported to build and maintain links with family and friends. One service user stays with family members regularly at weekends. Service users are fully involved in selecting and shopping for food. Staff have followed correct procedures for the storage of food. Menus are varied and personalised for service users with specialist dietary needs, for example people with diabetes. A nutritionist has recently completed a nutritional assessment for a service user. Recommendations made by the nutritionist should be incorporated into care plans. Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 Service users receive personal support in a way that they prefer to maximise their privacy and independence. Procedures are in place to recognise and monitor healthcare needs and to respond promptly to any identified concerns. More attention is required to risk management especially in supervising service users so that unnecessary risks to their health and safety are identified and removed. EVIDENCE: Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 15 The staff group are of mixed gender reflecting the service users group. Personal care is provided in the privacy of locked bathrooms and bedrooms using aids and adaptations as required by assessment. Two of the four service users required a higher level of care and support with personal care. The inspector observed some good practice between support workers and service users. One service user has become less steady on her feet on occasions. She liked to walk about despite this. A support worker gently supported her while explaining at the same time how to move safely. A service user that experiences excessive secretions from her mouth was supported to manage these effectively and discreetly. A service user sustained a burn/scald to her chest recently. An investigation was undertaken but it was not concluded whether it had been sustained from spilling a hot drink or direct access to hot water supply. The risk assessment stated that she was to be supervised by one staff member at the home and by two people when outside the home. The service user had however been left unsupervised on some occasion to sustain this burn. Times for getting up and going to bed are flexible, although routines and planned activities determine the time for getting up on weekdays. Records of the regular visits made by general nurses to administer medication to a service user that has Diabetes. There were good records maintained of daily progress. The condition of service users was recorded in handover/shift planner. There was evidence from viewing records that the healthcare needs of service users were monitored carefully and that necessary action was taken to address any problems or areas of concern identified. All service users attended appointments with the GP for routine check ups during the inspection. Three service users attended the dental appointments the previous day. Senior members of staff have been trained to check the Blood Sugar for a service user with Diabetes. Recently appointed support staff have received training from colleagues. This is not appropriate and is dealt with under Standard on training. Medication is supplied in Blister packs to the home. Records of administration showed no errors and had signatures present for all medication administered. A requirement was made at the previous inspection that regular audits of medication stock are completed. Evidence was that these had started but they should be maintained consistently and frequently. Staff have received training in the administration of medication but competencies in this have not been verified. The operations manager should ensure that a report is sent to the inspector confirming that staff competencies in medication administration have been verified. Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 There is a prompt response to complaints received. Investigations are undertaken and actions agreed to prevent reoccurrence of issues arising that lead to the complaint. Procedures adopted for responding to unexplained injuries sustained by service users have not been robust. EVIDENCE: Positive steps have been taken by the organisation to address promptly complaints received at the home. The views of neighbours that were inconvenienced have been taken on board. A meeting has taken place with the local community to hear their views and to agree an action plan to address the noise issues raised. Actions taken to respond to inconveniences caused and to avoid any further upset include using televisions and radios at acceptable times, also the use of slippers by night staff, rearranging the positioning of televisions and radios from walls adjoining neighbouring property. Not all the staff team are fully aware of the appropriate procedures to follow and to safeguard service users from neglect or abuse. On viewing records relating to service users welfare occasions were identified relating to the non-reporting of injuries/bruising sustained by service users. A service user had sustained unexplained bruising some months prior to the inspection. No incident reports had been made and forwarded to placing social worker or the Commission. Body mapping charts although on care files were not completed as and when necessary. Recently a service user sustained a burn/scald. Appropriate notifications had not been made within acceptable periods. Staff require further training and guidance on Adult Protection Policies and Procedures to safeguard service users from neglect or abuse. Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 29 30 A comfortable and homely environment is provided. The safety of service users has been compromised when staff did not recognise that notable changes to hot water temperatures needed to be addressed promptly. EVIDENCE: It is a comfortable and homely environment. The premises are brightly decorated and pleasantly furnished. Two bedrooms viewed were comfortable and personalised. The premises were clean and hygienic. There is a comfortable, nicely furnished through lounge/dining room. The rear garden is small. The pathway is uneven. This shortfall was identified at previous inspections and remains outstanding. Prices had been received from a number of contractors for the conversion of this area into a sensory garden. This was the subject of a requirement at the previous two inspections. It is restated with an extended timescale to enable achievement. There are two bathroom/shower areas. An area of concern relates to how the hot water supplies are regulated and monitored. While weekly monitoring of hot water temperatures for bathrooms and bedrooms take place a number of taps discharged water at temperatures above 43c for the month of September. Despite the fact that a service user had sustained scalding/burn to her chest Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 18 water temperature controls had not been attended to. An Immediate Requirement letter was issued to the home to respond promptly to these concerns. Confirmation was received by letter that these had been responded to promptly. For one service user an assessment had been undertaken by an occupational therapist (OT) regarding the shower unit. Recommendations were made for the shower to be adapted but these had not been responded to. A service user displayed deterioration in her mobility. She had not been assessed recently. A referral should be made to the OT so that an assessment can be completed. Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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 32 34 35 36 Staff individually and collectively have the right qualities and attributes but need to have these developed. A staff training and development programme is needed so that staff team have the appropriate skills and knowledge and can meet the assessed needs of service users. EVIDENCE: Positive steps have been taken to address poor practice and staff that were not interested in their roles. Only three of the original staff team remain in employment. Staff appointed demonstrated empathy and an understanding of service users’ needs. From speaking with two members of staff it was evident that they enjoyed their role and wanted to develop their skills further. One staff member has had previous experience with the client group. There were clear indications that staff had developed relationships with service users since their appointment. There have been notable improvements in the recruitment procedures with more information available for all new staff. It was the subject of a requirement at the previous inspection that essential information be sought for all new staff before they commence work. The recruitment procedures are not as robust as they should be and do not meet the national Minimum Standards. Three staff files were viewed. Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 20 An example was seen of a new member of staff commencing work before an up to date POVA check had been completed. Confirmation was received that the POVA check had come through two days later. This is not in line with correct recruitment procedures. All the relevant information must be available for staff before they commence employment. References supplied from previous employment were not authentic and did not have any company stamp. The change in staffing personnel has directly affected the number of staff with NVQ qualifications. Records were produced of staff enrolling on NVQ courses before the end of the year. The requirement set at the previous inspection remains outstanding. There is a form of induction for new staff but it is not a structured induction and foundation training according to Sector Skills Council specification. The manager had completed a training needs assessment for staff. From this there were indications that some of the long serving staff had not completed necessary mandatory training. A staff-training pathway was supplied to the inspector. It outlined the additional training planned for all members of staff that was specific to the needs of service users. It covered all areas of immediate identified need. The organisation has not completed a comprehensive training and development plan for the staff team. No details were received of dedicated budgets for the training and development of staff. Improvements were found in the way staff are supported and supervised. A staff member spoken to has found that she is given more support in her role. One to one supervision records were observed for members of staff. Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 40 41 The management of the home has not been effective due to the lack of consistent and regular support and supervision. This has resulted in service users not always receiving a consistent quality of care. Poor practices demonstrated by a small number some staff is not always identified and addressed. EVIDENCE: The newly appointed manager has been in post for two months. She has an NVQ Level 3 in care. She has not completed the Registered Managers Award. Early indications from staff were that the manager was keen to make improvements but that she would need the support from senior management to achieve this. She must submit a completed application form to register with the commission. In her role she must take a strong lead to address the shortfalls identified in the workplace. The organisation has not developed an effective quality assurance system for the home. It was detailed as a requirement at the previous inspection that an annual development plan is formulated for the home based on a systematic Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 22 cycle of planning- action- review, reflecting the aims and outcome for service users. Further development is required to this plan. The policies and procedures at the home have been recently updated. They were signed and reflected current legislation. Record keeping at the home was not all up to date, examples such as irrelevant and outdated care plans and risk assessments are referred to in relevant standards. Another area for concern was the failure of staff to make appropriate notifications both to the social workers and to the Commission. When the inspector arrived the home was empty with all service users and staff out in the community. The home however was not secured and had several windows left open on both the ground levels and upstairs. Records viewed of testing completed of portable appliances in the home. Fridge and freezer temperature monitoring were not consistent. Staff had failed to report that the temperature was no longer working. Environmental risk assessments were available for the home. Due to recent changes to staffing and from the shortfalls identified the environmental risk should be reviewed. Records were seen of regular fire checks, these included observations of fire extinguishers. The last fire drill had taken place two months earlier. . Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 2 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kirkstall Lodge Score 3 2 3 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 3 2 2 X DS0000053104.V256481.R01.S.doc Version 5.0 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6YA9 Regulation 12 15 Requirement The Registered Person must ensure that the assessment of the service users’ needs is a) kept under review b) revised at any time when it is necessary to do so having regard to the changes of circumstances. Care plans to reflect how assessed needs will be met. Updated care plans and risk assessments that reflect current needs must be completed within 14 days of this inspection, i.e. 20 October 2005. Subject of an Immediate Requirement. Confirmation of compliance achieved on 20th October 05 The registered person must ensure that the management and support service users receive to help with DS0000053104.V256481.R01.S.doc Timescale for action 20/10/05 2 YA7 20 30/11/05 Kirkstall Lodge Version 5.0 Page 25 3 YA9YA19 13 (1) c 4 YA23 13 (6) 5 YA27YA24 23 (2) 12 (1) management of their finances is transparent and that individual accounts held by service users are retained at the home. The registered person must 30/11/05 ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated, service users requiring one to one supervision must not be left unattended. The registered person must 30/12/05 ensure that staff are provided with adult protection training. Placement social workers to be notified immediately of any unexplained injury sustained. 08/10/05 The Registered Person must ensure that the home is conducted in a manner to make proper provision for the health, safety and welfare of service users. Hot water temperatures in washbasins and bathrooms/showers must be regulated and not exceed 43 c. To be achieved within 48 hours of inspection. 6 YA28 12 16 23 7 YA29 13 14 23 The registered person must ensure that the rear garden is suitable to meet the needs of all service users (the uneven surface must be repaired or replaced). Timescale extended from 30/06/05 to allow consideration for further development. The registered person must ensure that recommendations made by the Occupational Therapist are responded to and that necessary adaptations identified are made to the DS0000053104.V256481.R01.S.doc 30/12/05 30/12/05 Kirkstall Lodge Version 5.0 Page 26 shower on the ground floor. 8 YA32 18 The registered person must ensure that there is a timetabled plan which outlines how a minimum of 50 care staff have achieved NVQ Level 2. The registered person must ensure that essential information is available for all new staff before they commence employment. Professional references must be authentic and verified, CRB and POVA checks must be sought for all new staff before they commence work at the home. The registered person must ensure that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’. Previous timescale of 27/05/05 not met. The registered person must ensure that the manager applies to the CSCI for registration as the manager of the home. The registered person must ensure that the manager receives the necessary support and guidance and training necessary to manage the home. The registered person must ensure that an annual development plan is formulated, based on a systematic cycle of planning-action-review, reflecting aims and outcomes for service users. Previous timescale of of 27/05/05 not met. The Registered Person shall give notice to the Commission without delay of DS0000053104.V256481.R01.S.doc 30/12/05 9 YA34 13 19 30/11/05 10 YA35 18 (1) c 30/11/05 11 YA37 9 30/11/05 12 YA37 10 18 (1) c 30/11/05 13 YA39 24 30/11/05 14 YA23YA41 37 06/10/05 Kirkstall Lodge Version 5.0 Page 27 15 YA42 23 (1) a b 16 YA42 13 (4) c (c) any serious injury to a service user. The registered person must ensure that attention is paid to security at the home and that the premises are secured at all times The registered person must ensure that attention is paid to the regular recording of freezer and fridge temperatures. 30/11/05 30/10/05 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 YA1 Good Practice Recommendations The registered person should ensure that each service user should have it explained by his/her named key worker the content of the service users’ guide before it is place in their care file The registered person should ensure that a report is sent to the inspector confirming that staff competencies in medication administration have been verified The registered person should ensure that a referral is made to the OT for a service user experiencing deterioration in her mobility The registered person should undertake a review of service users’ needs and reflect this in current staffing levels The registered person should ensure that the environmental risk assessments are reviewed. 2 3 4 5 YA20 YA29 YA33 YA42 Kirkstall Lodge DS0000053104.V256481.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. 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